October incongruities and congruities.

 

Matula Thoughts 

Oct 5, 2018

October incongruities & congruities.
3813 words

 

One.

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

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

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

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

 

 

Two.

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

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

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

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

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

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

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

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

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

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

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

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

 

Three.

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

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

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

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

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

 

Eight.

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

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

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

 

Nine.

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

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

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

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

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

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

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

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

 

Ten.

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

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

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

 

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

September skies and serendipity

Matula Thoughts Sept 7, 2018

September skies and serendipity
3662 words

 

One.

Intersecting contrails caught my attention, looking out from the Mohs Surgery area (above) in our Rogel Cancer Center, and recalled the clear skies of September 11, 2001, when commercial air traffic was grounded, leaving a pristine and surreal atmosphere visually and psychologically. Transient evidence of people in aluminum tubes flying through the sky, contrails are daily proof of the enormous planetary human impact. New technology, such as the flightradar24 app that Bob Gibbons showed me in Seattle last spring, gives rough details of a particular flight if you aim an iPhone at a plane in the sky. Below, taken from the Amana Colonies in Iowa last month, is evidence of Delta 3882 Canadian Regional Jet going from Minneapolis to St Louis on July 27, containing anonymous people, particularities, and myriad stories going about their business in the midwest.

September is a transition month, as summertime vacations give way to serious business of autumn. In the Medical School, academic medicine takes center stage when fall meetings convene and new ideas get shopped around world marketplaces of research, education, and clinical care. Faculty become traveling salesmen and saleswomen not only for their ideas, but also for their presentation skills, and the University of Michigan brand in general. Trainees follow in those footsteps, adding to the thousands of Michigan people shuttling around in the skies at the vanguard of contrails, studying and rearranging PowerPoint presentations on laptops. Key meetings for our faculty this fall include the Society for Urologic Oncology, the American College of Surgeons, the North Central Section of the AUA (our Gary Faerber – now at Duke – is the President), and the Society for Pediatric Urology.

 

Two.

Rene Magritte, an artist who lived in and through the disruptions and transitions of 20th century World Wars, offered an intriguing view of Homo sapiens and earthly skies in two paintings he called The Human Condition. No one can know for certain what he had in mind with these, although the title hints at the rich imagination, ambiguities, illusions, and contradictions of human nature. Probably no other species looks to the skies and finds as much “content” as we do. Other life forms may, at best, derive some practical information regarding sunlight, time of day, precipitation, danger, or opportunity, but H. sapiens looks at the sky with its clouds and contrails, and builds rich imagination from excited neurons.

[Above: The Human Condition 1933. Below: The Human Condition 1935.]

Euclidean Walks, a later Magritte painting from 1955, pursues the same idea of a painting within a painting, that is, an imagination of imaginations, joining my and your imaginations to those of a Greek philosopher nearly 2.5 thousand years ago (below).

 

Three.

A picture is said to be worth a thousand words. The original author of this thought is unknown, although it is likely that similar thoughts spontaneously popped into many human brains over the millennia since the early times of cave art. We all appreciate the qualitative truth to this phrase, but Isaacson’s book Leonardo da Vinci, offers data to support that truth, at least within an order of magnitude. A chapter on The Nature of Man, discussing human proportion, states:

“Using at least a dozen young men as models in his Corte Vecchia studios, he measured each body part from head to toe and produced more than 40 drawings and six thousand words.” [p. 219]

That is, Leonardo used six thousand words to consider 40 pictures, giving a word to picture ratio of 1:150, surpassing conventional wisdom of 1:1000 for the average picture. Granted that he wasn’t necessarily describing all the details of each of the pictures, as merely talking about them, but data is data so you can take what you want from the numbers. Later in the book, Isaacson quotes Leonardo from a debate in 1498 on the relative merits of arts and sciences.

“If you, O poet, tell a story with your pen, the painter with his brush can tell it more easily, with simpler completeness, and less tedious to follow. Take a poet who describes the charms of a woman to her lover, and a painter who represents her, and you will see where nature leads the enamored critic.” [p. 262]

Mona Lisa (above, at the Louvre) is the obvious picture to accompany that thought.
Words are magical finite bits of information, but a single picture conveys a multitude of information, open to vast possibilities of imagination by any one individual and leaving other vast possibilities potentially detectable by someone else. While words and pictures may have had common origin in human history, visual art has extended from the representational to the abstract and Eric Kandel explains how our brains process these two different art forms in quite different ways. [Kandel. Reductionism in Art and Brain Science, Columbia University Press, 2016.]

 

Four.

 

The contrails reminded me of the acid-base balance curves I studied as a medical student, becoming nearly indelible in my brain, needing occasional refreshment for board exams and teaching sessions. Horace Davenport (1912-2005), renown physiologist and legendary historian of the University of Michigan Medical School, pioneered the modern understanding of acid base chemistry with those curves [Davenport HW. Danish M. Bull. 1955, The ABC of Acid-Base Chemistry, University of Chicago Press, 1974.] [Austin WH. Acid-Base balance. Amer. Heart J. 69:691, 1965.]

Horace was an iconic professor here at UM Medical School. He rose to the top of his field as a physiologist and was an inspiring classroom teacher. During his early career, at the Mayo Clinic, he defined the gastric mucosal barrier, working with Charles Code, and in 1947 his ABC text translated mysteries of basic physiology into working knowledge for generations of medical students and clinicians using those contrail-like curves. [Davenport HW, University of Chicago Press, 1947.] The ABCs is still in print with the original preface, admonishing students to work hard if they are to achieve understanding:

“Unfortunately, there are no effortless roads to a knowledge of acid-base chemistry, and there are no easily memorized rules-of-thumb that can be applied at all times in the clinic without risk of disaster.”

After Davenport stepped down as Michigan’s chair of physiology he became unofficial historian for the Medical School, providing a book for the sesquicentennial. [Davenport HW. Not Just Any Medical School. 1999.] I came to know Horace through the Victor Vaughan Society and its periodic dinners of medical students and faculty. Horace was unusually tall and in his later years when the occasion met at our home I would cautiously walk him out over our uneven steps and dirt road to his car, concerned for his unsteady gait. We remained in touch throughout his retirement. At one point (June 3, 1998) he wrote me from Alabama:

“I am living in my wheelchair in complete physical, social, and intellectual isolation and with rapidly increasing disability in what is essentially comfortable prison. I try to keep occupied.”

If my small collection of his neatly typed letters is any indication, he seemed to have kept reasonably well occupied for the next seven years of his life. [Obituary by Ivan Oransky. The Lancet. 366:1260, 2005.]

 

Five.

Two Horaces. Horace Davenport was a perfectionist and an exacting teacher. His son, Robertson Davenport and UM Professor of Pathology, kindly sent me the portrait shown above. I recall one episode of my instruction from Horace after I sent him recent work we had published on Trendelenburg, a paper that sprang from a discussion with medical students regarding the German surgeon and informed by an obscure autobiography (translated from German to English) we obtained from an Egyptian library (the beauty of inter-library loan!). Our paper detailed urological contributions of the great German surgeon that had not been widely appreciated. [Bernstein et al. Beyond the Trendelenburg Position. Surgery. 126:78, 1999.]

I thought we had done a good job of scholarship and must have been hopeful for Horace’s praise when I sent him a copy. He replied, after offering some personal news:

“I have only one comment on your Trendelenburg paper, and that is to protest the customary misuse of the word serendipity in the first paragraph. A Chicago lawyer named T.G. Remer became so annoyed that he wrote an entire book on the word: Serendipity and the Three Princes, Norman, OK. University of Oklahoma Press, 1965. I urge you to read the book which is in the Graduate Library. With best regards, Yours, Horace.” [Letter. August 24, 1999.]

Months later I went to the library, checked out the book, and read it. Horace was correct, having instructed me once again on many levels.

Remer had a compelling interest in this 14th century Persian fairy tale that had been translated into Italian and published by Michele Tramezzino in Venice in 1557. English art historian Horace Walpole (1717-1797) created the word serendipity based on a detail in the story in which the three princes discerned the nature of a lost camel through “accidents and sagacity.” Walpole no doubt had read Tramezzino’s version of the “silly fairy tale,” as he called it in a letter on January 28, 1754, when he originated the neologism. [Wikipedia, The Three Princes of Serendip.] Remer commissioned an English translation of the Italian story and included it in his book, a lovely a tour-de-force and obvious labor of love. The point Horace Davenport wanted me learn for myself was that serendipity has two necessary elements: luck and sagacity, or good fortune and wisdom, depending on how you phrase it. He was rightfully offended when I used the term as a mere synonym for dumb luck and I doubtless offended the spirit of Horace Walpole as well. [Below. Horace Walpole by Sir Joshua Reynolds. 1756. National Portrait Gallery, London.]

 

Our Medical School Center for the History of Medicine has a yearly Davenport Lecture that featured many superb speakers over the years including Abraham Verghese, Catherine DeAngelis, David Oshinsky, and Sherwin Nuland. The speaker next spring remains to be determined.

 

Six.

Art & medicine notes. Somewhere recently I came across the phrase “human confection” and wish I could recall the source. Perhaps it was in a newspaper or magazine, but it seemed an interesting conjunction. At first thought, confection indicates a sweet food item, perhaps visually decorative as well, but the meaning goes deeper and traces back to Middle English confescioun, coming from old French confeccion, and derived from Latin cōnfectiōnem meaning “to make” or “to prepare” or “to do.” Modern usage, aside from food, pertains to the process or result of preparing or making or composing things, things that may be elaborate, amusing, delicate, or possibly contrived. This is an almost uniquely human range of possibilities, so it seems that human confection fits nicely. Perhaps this is even better than the phrase human condition, that more or less merely indicates a particular state of being. H. sapiens are singularly distinguished by the range of things they do, physically, mentally, and trans-generationally.

Artists usually tell something of themselves and the world through their work. Some produce skillful representations of the real or imagined world. Others produce representations of their personal feelings. Some offer work of little immediate meaning to a viewer but, on inspection and with some effort, that work can provoke thought and interpretation, delivering valued personal meaning. Both art itself, as a generality, and medicine, as a term for health care delivery at large, are genuine human expressions of caring, opinion, belief, and observation. Both are human arts applied on a canvas of technology.

Artificial intelligence is a mildly offensive term, since intelligence is a wide-ranging biological phenomenon, and taken to entirely different dimensions of imagination by human brains. Humanism, naturally, is part of that imagination: we can imagine a better world that is kinder, safer, happier, and more sustainable than the world of yesterday and today. Self-learning algorithms can’t quite do that. We can make devices that could produce a Piet Mondrian or Jackson Pollock type of work, but those works would be devoid of the human context of the artists.

What people experience as a physician’s art is made better by the evidence physicians assemble and by their sense of humanity, evolving with their careers and growing with immersion in the soup of human culture, to use the term from Dawkins.

 

Seven.

West Shore Urology (WSU) in Muskegon became a part of Michigan Urology only ten months ago and on my visit there last month it was nice to see the Block M logo on the sign in front and on the lab coats of the team. The photos at the front of the clinic show founder Tom Stone and the original partners, along with the current team, although the newest member, Adam Walker, needs to appear on the wall. [Below: clinic wall and Adam & Jaclyn Walker with Malissa Eversole at AUA Nesbit reception, 2018.]

 

We incorporated the excellent WSU faculty in our Urology Department and also acquired its clinical team and facility as a new Ambulatory Care Unit (ACU), but it is unique among the other 180 plus ACUs of Michigan Medicine in that it does not have the HOPD designation that confers payment advantages to ambulatory units unattached to hospitals. At first glance this may seem to have been an odd business decision for us, but this opportunity will force us to learn how to make clinics work in a health care world that is likely to dissolve the HOPD advantage.

[Above: WSU office staff Tracy Dinh, Jessica Phelps, Bre Rodgers, Michelle Halldorson, Gabby Perez. Below: Cris Bench, Brian Stork, Carrie Brown.]

Brian Stork, beekeeper and urologist, was in Ann Arbor just last month to give a Grand Rounds presentation linking work force burn-out to adverse childhood experiences (ACEs). It was at his instigation that I found myself stopping for lunch, the next day, in the Amana Colonies, after I happened to fly into Iowa, explaining the contrail shown earlier.

In between WSU and Ann Arbor is Metro Health Hospital in Wyoming, Michigan, south of Grand Rapids, and shown above shortly before a rainstorm last month. Metro Health became a part of Michigan Medicine in January 2017, and like our partnership in Muskegon, it is a part of an essential regional network. Peter Hahn was recently named CEO at Metro. Nearly all of our fellow health systems and academic medical centers in the state and nation have been networking vigorously in their regions and beyond for the past 2 decades, although we, at the University of Michigan, have been late to the process, but we are catching up. Our regional growth is sometimes viewed unhappily by other health care systems, but such is the nature of healthy competition. All patients need regional alternatives to find the right care at the right time and in the right place that best fits their individual particularities. Sometimes that best fit is with Michigan Medicine, sometimes it is not.

[Above: Joint Venture ceremony last month with David Miller, Rob Casalou President and CEO Mercy Health & St. Joseph Mercy System, Travis Souza, Dave Spahlinger, Alon Weizer, Denise Gray-Felder.
Below: Richard Gilfillan CEO Trinity Heath, Nancy Graebner President & CEO St. Joseph Mercy Chelsea, David Miller, Donna Lasinski Michigan State Rep 52nd District.]

Last month we (Michigan Medicine) finalized a joint venture with St. Joseph Mercy Health System Chelsea Hospital. It has been implemented with Family Medicine, Surgery, Gynecology, Ophthalmology, and Urology. Michigan Urology has a long history with Chelsea Hospital. Howard Usitalo and C. Peter Fischer are Nesbit alumni (1986 & 1979) with deep roots in the hospital and community, now joined by Andre King  and Dave Lutchka PA. Mike Kozminski from our department has held a Saturday morning clinic at Chelsea for the past 4 years.

Anticipating the joint venture, Will Roberts’ Endo-urology/stone division has been active with a percutaneous renal unit aligned with Radiology and Casey Dauw has been a consistent presence in. that effort for much of the past year, along with Alon Weizer from our Uro-oncology division.

 

Eight.

Visiting professors enrich teaching programs with new ideas, novel techniques, and different teaching skills. They challenge us with new facts and ideas, and their presence builds new connections and collaborations. When accompanied by a partner they show, by example and in conversations, how work life and personal well-being through family are negotiated – and this is especially important to our trainees and younger faculty.

Visiting professors also cost money and take time out of the working day, so we must carefully balance the academic and clinical missions against the economics of an academic medical center. A supportive departmental working culture, excellent health care system leadership, and a strong philanthropic base make this balance not only possible, but robust for us.

Mahesh Desai, a world-class urologist from Gujarat, India, was in Ann Arbor a few weeks ago to visit our department, meeting residents and younger faculty, and giving Grand Rounds before heading to Chicago for the DUST Course #4 organized by Khurshid Ghani and Will Roberts. It’s good to know people around the world like Mahesh. A number of years ago I got a call from one of our Engineering School faculty members who was on an academic trip in India and had colic from a kidney stone. An easy phone call then connected me to Mahesh and the Muljibhai Patel Urological Hospital in Nadiad, a hospital he founded with Dr. V.V. Desai. Our engineering colleague professor quickly had a solution in hand. [Above: from left, Dr. Desai & his nephew Udhav Doctor, Priyanka Gupta, Khurshid Ghani, James Tracey, Ted Skolarus, Ed Kleer, Will Roberts, Ganesh Palapattu, Mahendra Bhandari. Below: Thompson]

Our Health Services Research Symposium will reconvene this month. Chad Ellimoottil and Lindsey Herrel have organized this with 22 speakers at the Power Center September 13-14.  [www.hsrsymposium2018.com]

We alternate the McGuire and Montie visiting professorships each year. Two years ago the Jim Montie lecture featured the extraordinary Ian Thompson. This October Dave Penson will come from Vanderbilt as the Montie Professor. [Below: Dave & Jennifer.]

 

Nine.

Elusive evidence. With September, summer 2018 recedes in the rearview mirror, its pleasures having vastly outnumbered its minor annoyances, such as pesky mosquitoes, no-see-ums, houseflies, ticks, and other bugs. Even so, a recent article and letter to the editor in JAMA grabbed my attention and introduced me to the BUGG Trial. Acronyms abound in medicine, but clinical trials have taken them to a new level of silliness. Benefits of Universal Glove and Gown is the name for this trial, reported in an article by Harris et al (JAMA 310:1571, 2013), that investigated antibiotic-resistant bacteria acquisition in intensive care units.

The letter-to-editor and a current paper questioned the evidence for either employing or discontinuing contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE). [Letter: AB Kressel. JAMA. 320:407, 2018; Article: Rubin, Samore, Harris. JAMA 319:883, 2018.] The letter makes the important point that contact precautions convey significant burdens of material costs, time of multiple implementations, and wear and tear on the workforce. While contact precautions seemed a reasonable solution for a difficult problem, its self-righteous standardization may well provide not just “no value added”, but an even worse effect of value subtracted from the health care equation. Kressel notes:

“Inaction is not the only response to the status quo in the absence of strong evidence. In the case of CPs for MRSA or VRE, it may be reasonable for each institution to make a choice based on local hand hygiene, MSRA, or VRE rates, use of chlorhexidine bathing, and use of single-occupant patient rooms.”

This last point hits close to home. First, single-occupancy patient rooms are implicit in the standard of hospitals in the industrialized world. Our local exception to this is most peculiar. [Simon et al. J Health Serv Res Pol. 21:147, 2016.] Second, the world-wide craze for hand sanitizers is, it seems to me, a nearly fraudulent alternative to simple hand washing, provided clean water and soap are available. The popular hand sanitizers have strong effects on the normal microbes of our microbiome and environment, but virtually no help with killer spores and mixed effects with viruses, some being inactivated while others are not. The visual theater of hand sanitization on entering patient spaces brings comfort to audiences, but the display tends to bug me if there is a sink nearby.

 

Ten.

Summer nostalgia. September Song was written for the 1938 Broadway musical Knickerbocker Holiday, and resuscitated for the 1950 Hal Wallis film, September Holiday, and again in the British sitcom May to December that ran from 1989 to 1994. Ezio Pinza, Bing Crosby, Frank Sinatra, Nat King Cole, Patti Page, Eydie Gormé, Pat Boone, Dean Martin, Jimmy Durante, James Brown, Lena Horne, Ella Fitzgerald, Willie Nelson, Dee Dee Bridgewater, and many others have recorded this classic. Of course, with only 12 monthly names to inspire music and movies, it’s no surprise that September gets recycled, currently in a new September Song written and sung by JP Cooper.

Kurt Weill composed the music and Maxwell Anderson wrote the lyrics for the classic September Song, a tune produced rather hastily for the musical production Knickerbocker Holiday in 1938. The song was made specifically for the “gruff voice and limited vocal range” of the lead actor, Walter Huston, who was playing the aged dictator Peter Stuyvesant. [Wikipedia.] While the Broadway musical confection lasted only 6 months, the song has been remarkably durable and it is the Jimmie Durante version (first recorded 1955, album 1963) that I particularly favor, perhaps most resembling the original version in character. The actual content of the lyric and musical is twofold and dark: the specific story of forced marriage of a young woman to an elder tyrant while she loves another younger man, and the general metaphor of the September of our lifespans as framed by the monthly calendar.


 

CORRECTION: Last month’s What’s New/Matula Thoughts contained an egregious error (corrected in updated versions), where I misspelled the name of one of my favorite authors, the extraordinary John McPhee. My apologies to you and to him. It’s not so much that I blew the fact as that my brain and keyboard translation fumbled, as seemingly happens sometimes in this September of my career. Perhaps this is a new disorder one might call dystypia, a fumble less infrequent than revealed by these edited pages.

 

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

Sunrises, sunsets, & summer imaginations

Matula Thoughts Aug 3, 2018

Sunrises, sunsets, summer imaginations & facts

3951 words

One.

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

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

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

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

 

Eight.

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

 

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

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

[Above: Martha Bloom, George and Peggy.]

 

Nine.

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

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

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

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

 

Ten.

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

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

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

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

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

 

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

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

Birthdays, graduations, and centennials

July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.


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

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

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

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

 

Four.

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

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

 

Five.

 

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

 

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

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

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

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

 

Nine.

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

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

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

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

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

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

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

 

Ten.

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

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

Thanks for reading Matula Thoughts this July, 2018.

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

 

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

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

Rules, boundaries, and stories

DAB What’s New June 1, 2018

Rules, boundaries, & stories

3722 words

 

One.

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

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

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

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

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

 

Two.

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

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

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

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

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

 

Five.

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

 

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

But now back to 2018.

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

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

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

 

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

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

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

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

 

Ten.

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

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

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

 

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

Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

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

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

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

 

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

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

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

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

 

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

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

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

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

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

 

Four.

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

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

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

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

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

 

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

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

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

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

 

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

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

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

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

[Below: Jean and Mary DeKernion.]

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

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

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

 

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

[Above: Grady Festschrift group photograph.]

 

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

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

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

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

 

Eight.

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

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

 

Nine.

 

 

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

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

 

 

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

[Above: The Rock.]

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

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

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

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

 

Thanks for reading Matula Thoughts.

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

Spring and all

DAB What’s New Apr 6, 2018

Spring and all

3476 words

 

One.

Spring and All is a collection of work in the early writing career of William Carlos Williams, a New Jersey general practitioner in the first half of the past century. The slim volume is an odd collection of alternating prose and free verse, best known for a poem that begins, “By the road to the contagious hospital…” A recent edition of the work includes an introduction by CD Wright with a phrase comparing Williams to an earlier poet from New Jersey, Walt Whitman. “Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers.” [Spring and All. WC Williams. New Directions Book, 2011.]

Published in 1923, Spring and All came during a time that strained human understanding, juxtaposed between WWI and the Influenza Epidemic that preceded it, and the Great Depression a decade later. Only one year before Spring and All, TS Eliot published The Waste Land, a more obscure and academic poem with complex literary references and snippets of multiple languages. The landscape that Williams presents is not quite so bleak, nor is April (spring) quite so cruel. Still, the Williams terrain is far short of a Disneyland, although some promise is held out as “sluggish dazed spring approaches…” Williams embraced the season cautiously, feeling perhaps some recovery from the recent devastations of war and epidemic, thankfully unaware of the impending economic catastrophe that ran from 1929 through most of the 1930s. In much of the work Williams conveys an ominous sense of mankind’s tendency toward self-destruction. [Above: by the path to the Frankel Cardiovascular Center; below, Williams, Wikipedia.]

Whatever constraints the world may bring to bear, spring is generally a season of optimism and refreshment. After a rough winter in much of the northern hemisphere including North America, Europe, Russia, Japan, and Korea, we are glad for spring and all it brings.

[Above: Signs of spring at home, early daffodil and tiny blue flowers sprouting with a few flecks of overnight snow. April, 1, 2018.]

 

Two.

We pursue that idea of a “great human understanding” in the practice of medicine, an understanding never fully realized, but one that grows even as challenged by the practicalities of each day and the idiosyncrasies of each patient. Physicians “take histories” and examine evidence in pursuit of authentic narratives that allow them to understand the conditions and needs of their patients.

Using the phrase, the practice of medicine, the final word medicine seems increasingly parochial and archaic. In this era of specialty healthcare, “the team” has supplanted the solo practitioner and the term medicine, implies a drug or a specific branch of learning and practice itself more than encompassing all of healthcare. Reference to the practice of medicine is parochial in that it excludes other essential practitioners or binds them up within the terminology of my branch of healthcare.

Yet, the practice of medicine has a comforting ring to it, recalling Hippocratic times when the practitioner’s responsibilities were outlined in a sacred oath and the profession of medicine was as much art as science (observation and reasoning). The historic sense of the professional calling of a doctor tending to a patient worked well up through much of the last century, exemplified by horse and buggy house calls, Norman Rockwell’s depictions, Albert Schweitzer’s humanitarian work, and Marcus Welby’s television dramatizations. The one-on-one relationship of a practitioner to a patient is still essential to excellent healthcare and it is a relationship that offers magical moments for greater human understanding. The dilemma in modern healthcare is that this special duality must find a place within the great tent of the team.

These last thoughts beg a big question – do our students and successors understand the earlier eras of healthcare that today’s healthcare is predicated upon?  Do they know who Hippocrates, Galen, Avicenna, and Lister were, or what they achieved? Do our students know of Norman Rockwell, Albert Schweitzer, or Marcus Welby? Should they know these things and how would they know of them? Today’s medical education, indeed all of healthcare education, falls short of the mark in teaching the history and context of healthcare. To some degree this should have been the job of higher education (we used to call it liberal education), but the need in medical school and residency education is even more acute. Without history and context, it’s hard to find values that are so essential to human understanding.

 

Three.         

Morel quandaries. Spring is morel time in Michigan. These wild and mysterious mushrooms defy all human efforts to cultivate and industrialize them. Experienced mushroom hunters, such as our friend and neighbor Mike Hommel, are skilled at finding and accurately identifying morels, and there are few things better on the palate than the end result of his searches.

[Above & below: morels]

Mushrooms, although not morels, play a pivotal role in the current film, Phantom Thread, but no more should be said for those who have yet to see this strangely elegant period piece and psycho-drama.

The morel (genus Morchella) evolved from a yeast only as recently as 20,000 years ago, according to some authorities, although others claim it is an ancient cup fungus as old as 129 million years (at this point, science has only deepened the mystery). Many morel species exist, perhaps 60, having distinctive and highly polymorphic honeycomb configuration allowing effective camouflage as pine cones. Morels have some relationship to recent fires and decaying fruit trees, but the exact formula of conditions for them to prosper remains elusive. The morel supports a multimillion dollar industry business of hunting and gathering. Had William Carlos Williams ever experienced morels, they surely would have figured in his Spring and All landscape: “Beyond, the waste of broad, muddy fields brown with dried weeds, standing and fallen patches of standing water the scattering of tall trees…” Morels are of some spring’s mysterious marginalia, happy little surprises of the season and all.

 

Four.

Daily practicalities confront and confound everyone, navigating their lives and work, and physicians do not get a free pass from them. In the horse and buggy era, a house call was no easy matter, given the inertia to leave a comfortable home at inconvenient moments, saddle up horse and a buggy, and then set off to the patient’s home. Electronic medical records among many other systemic constraints offer newer barriers to many practitioners today, and even those facile with keyboard medicine find they have traded spontaneous interactions with patients for new formulaic work flows of check lists, drop down menus, smart sets, and the lure of cutting and pasting.

Patients as well as healthcare providers must also deal with modern daily practicalities that are impracticalities, more often than not. Matters of finding time from work, transportation, parking, insurance forms, questioning at front desks, forms to fill out, and the incessant repetition of one’s story to an array of healthcare workers dampens the spirit of the human soul. Yet, an ultimate audience with a single healthcare provider (I use this more inclusive term because there are a number of categories of us) is usually a moment of immeasurable importance for patients, who are hopeful for someone to listen carefully to their narratives and gain an authentic understanding of their stories, their histories, instead of processing them into checklists and pre-written sentences and dot-phrases.

 

Five.

Williams began Spring and All with an admission of mixed optimism and inadequacy as a writer:

“If anything of moment results – so much the better. And so much the more likely will it be that no one will want to see it.”

Writers are vulnerable to mistakes and criticism of their work (criticism of themselves as people!) comes with the territory. Writers must accept that they will make mistakes and that some readers in their audience will find their work erroneous in parts or lacking in other ways. It may sting when errors are discovered, but that is a good thing in that correction (peer review, if you will) makes the product better and sharpens the writer’s own fact-checking and proof-reading going forward.

Criticism of style, argument, or quality of thought is a more painful challenge. Good criticism can sharpen an author, although some criticism will be wrong, misdirected, or even malicious. A writer has to hear it all, in the hope of learning and fine-tuning the craft of thinking and writing. Williams, in his writings, put himself “out there” for the world to inspect, criticize, fault, or praise. Some factor in his psyche compelled this expression of art, a factor closely tied to the art of his medical practice.

Spring and All is a quirky and complex collection of prose and poetry. Williams was around 40 years old when this was published and no sensitive novice. Yet he opened the work by admitting that he was not fully up to the task of appreciating and expressing that “great human understanding.” Furthermore, he revealed his vulnerability to criticism.

“There is a constant barrier between the reader and his consciousness of immediate contact with the world. If there is an ocean it is here. Or rather, the whole world is between: Yesterday, Tomorrow, Europe, Asia, Africa, – all things removed and impossible, the tower of the church at Seville, the Parthenon.

What do they mean when they say: ‘I do not like your poems; you have no faith whatsoever. You seem never to have suffered nor, in fact, to have felt anything very deeply…’”

Williams, like other physician-writers, double dip into the conundrum of human understanding in that they are simultaneously medical practitioners and writers, allowing each craft to fuel the other. It is astonishing that we don’t embrace the study of major physician-writers like Williams during medical training with the rigor that we rightly insist upon for other relevant topics such as genetics and pharmacology.

 

Six.

Hall of corrections. Last month I did a disservice to John Hall (Nesbit 1970), misattributing his practice to the Traverse City area, when in fact he worked in Petoskey. Ward Gillett (Nesbit 1985) set me straight. On the other hand, Tom Hall (Cleveland Clinic), who passed away in 2002 practiced urology in Traverse City, and Bob Hall (Wayne State University) also practiced urology in Traverse City. None of these urologists is directly related, although they and I and you are all cousins, according to a quirky book, It’s All Relative, by AJ Jacobs, who writes that all humans go back in time 8,000 great grandparents ago to a common pair of human ancestors who “hunted, gathered, and vigorously reproduced on the plains of Africa about 200,000 years ago.” [AJ Jacobs It’s All Relative, Simon & Shuster, 2017. P. xi.]

John Hall trained here at the University of Michigan exactly at the mid-point in our urology centenary and reminds me that he is thus the “fulcrum” of the Michigan Urology story. Knowledge and technology changed urology over the course of its century, but our mission and values have been constant and will likely remain so in the next iteration of departmental leadership.

 

Seven.

Blind eye. On an April day in 1801, a few days earlier in the month than today, the Battle of Copenhagen launched an enduring metaphor. The phrase of turning a blind eye is attributed to Admiral Horatio Nelson, of the British Royal Navy who had been blinded in one eye earlier in his career. The story goes that during the April Battle in 1801 his superior admiral, the cautious Sir Hyde Parker in charge of the overall battle and sensing defeat, signaled Nelson’s forces to discontinue their action. Nelson was a subordinate but more aggressive admiral and when told of the signal flag message, lifted a telescope to his blind eye and claimed that he did not see an order to desist. [Above: Nicholas Pocock, The Battle of Copenhagen, 2 April 1801, Wikipedia.]

The metaphor took on a life of its own and today would come to be called a meme – an idea, image, or behavior that spreads in a biologic fashion like a gene, replicating and modifying itself within and across cultures and times. The meme neologism is a contribution of Richard Dawkins, worth discussing at a later time.

Blind Eye is the title of a book by James Stewart, an investigation of the true story of a young physician who, for likely psychopathic reasons, poisoned or otherwise killed hundreds of patients and others until apprehended by the FBI. The title comes from the educators in academic medicine who turned blind eyes to his aberrant behavior. That story closely mirrors an earlier true story of a physician, involving Michigan Medical School graduate Edward Mudgett of the class of 1884, who went to Chicago after getting his MD, changed his name to HH Holmes and similarly dispatched scores of people for personal gain or oddly-derived pleasure. Eric Larson told that story in bestselling book, Devil in White City. I read both cautionary tales during a dark interlude in our own Michigan Urology story 20 years ago. Since Admiral Nelson, the phrase has become ubiquitous in English, you can hear it used early in the film, Black Panther.

 

Eight.

Certainties in life, April 15 for example. The author of the phrase claiming only two things are certain in life may never be known, but this is an obvious and nearly universal belief, cynical as it is. Most of us can’t seem to get around taxes, this month most particularly, and none of us will avoid the other absolute. Mortality always trumps economics.

It’s easier to confront economic issues than the mortal one and for an economist, life is viewed from the perspective of supply and demand tensions and balance sheets. Everything else, outside the economic issues, is a matter of “externalities.” The problem with economic models is that most of what really matters to people in the real world is reduced to those externalities. One can argue that Adam Smith’s book, An Inquiry into the Nature and Causes of the Wealth of Nations, suggested that economic wealth derived from all the externalities of the people, social groups, and markets working together. Economic wealth cannot be isolated from the externalities that create it.

Wealth of Nations was published in 1776, but Smith’s more astonishing book, The Theory of Moral Sentiments, came earlier in his career, in 1759 when he was only 36 years old. Permit a repetition here of the signature thought from that work.

“Howsoever selfish man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though he derives nothing from it except the pleasure of seeing it.”

Smith’s belief in mankind’s better nature preceded and likely superseded his ideas about the wealth of nations and the human economic model that today would be described as homo economicus, wherein human choices are primarily those of self-interest in daily life and in commercial markets, as he justifies in the following quote from the 1776 book.

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

Differing ideologies can exist harmoniously in the head of one person because human life is complex and not reduced to simple models. Its daily practicalities demand both functioning markets of commerce, where self-interest can rule the day if rules and opportunities are fair, existing on a bed of humanity anchored by kindness, kinship, and other characteristics of human civilization that have defined our species and allowed it to grow.

 

Nine.

            Spring, now and then. Emerging from a challenging winter, spring brings welcome change. When the general practitioner from Patterson, New Jersey published his collection in 1923, the specialties of medicine, the specialties of all of healthcare, were just starting to express themselves. Simultaneously serving as Dean of the Medical School, Professor and Chief of Surgery, and the University of Michigan urologist, Hugh Cabot was building a 1000 bed university hospital that would define the emerging medical specialties and initiate a urology residency training program that would come into fruition three years later with Charles Huggins and Reed Nesbit as Michigan’s first urology trainees.

After Cabot was fired by the Regents in 1930, Nesbit expanded the training program and would train 77 individuals including Jack Lapides who trained an additional 64. McGuire continued the process, for another 42 residents and fellows. Intervals of Bart Grossman and Joe Oesterling followed with another 8 and 16 trainees. Jim Montie, who led Michigan Urology to departmental status, trained 47 and with our graduation this spring 41 residents and 34 fellows will have been trained here under the present era of leadership, at last count. At this point I don’t know if Cabot trained any others besides Reed Nesbit and Charles Huggins, so the count of Michigan urology trainees stands at 329 to date.

This July a new set of residents and fellows will continue the traditional of urology education in Ann Arbor.  The residents will be: Kathryn Marchetti of the University of Michigan, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Our new fellows will be: Guilia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO).

Our new residents will complete their program in 2023, a full century after the spring of William Carlos Williams. They will continue a path of medical service that began well before Hippocrates. In their own careers and in their own unique fashions they will follow William Carlos Williams in search of a greater human understanding to alleviate illness and suffering. Evolving therapeutic tools, as attractive and incredible as they are, will always be secondary to the human understanding that deploys or restrains them. We hope to inspire the class of 2023 and our fellows to grow their capacities for human understanding just as they grow their knowledge and skills throughout their careers. That understanding will never be complete, but it can grow experientially, patient-by-patient, and humanely without being co-opted by the formulaic encounters of electronic medical record and artificial intelligence systems.

 

Ten.

Art Can Help is the name of a short book I recently found in Washington, DC, at the National Gallery of Art. With summer and our annual Chang Lecture on Art and Medicine (Thursday, July 19) soon ahead, I couldn’t resist the purchase. The author, Robert Adams, is a well-respected photographer and a superb writer and critic (photo below, Wikipedia). Coincidentally, like Williams, he came from New Jersey. This little volume is a series of short essays on a number of photographs, but is introduced by comments on two familiar Edward Hopper paintings. The title is provocative – help what, help how? Clearly the answer is up to the reader, but as I processed the book, it seemed that Adams intended to show how art (visual art, in this case) brings us closer to that great human understanding. It is a book I’ll return to, adding more and more marginalia and end-page references. [Art Can Help. Yale University Press, 2017.]

Let me close this monthly essay with two passages from Adams, reproduced with his permission.

            “Edward Hopper’s Early Sunday Morning is a picture upon which to depend. It is affirmative but does not promise happiness. It is calm but acknowledges our failures. It is beautiful but refers to beauty beyond our making.”

These four sentences offer an astonishing take on a well-known image, offering the ideas of depending on a picture, finding affirmation and calmness, the slightly buried idea of truth (not promising happiness, acknowledging failures), and the concept of beauty. Adams reminded me of a line in Spring and All by Williams: “so much depends upon a red wheel barrow.”

Toward the end of the book Adams inspects work by American photographer Anthony Hernandez, invokes the name of another great photographer from an earlier era, and affirms the importance of our choice to care:

            “Alfred Stieglitz said that ‘all true things are equal to one another’, and in that he spoke for most artists. They are convinced, despite having to sort through daily practicalities by triage, that everything is of immeasurable consequence…

For Anthony Hernandez, everything really means everything – a chair made of broken drywall, a fishing place where one might not want to eat the catch, a platinum-colored wig, … and everything means everyone – a woman with flowers in her hair, a man with a boxer’s broken face, an officer worker alone at noon with a book…

Why on the evidence of pictures is everything important?

First, because we are part of it all … our part being to be blessed with language that enables us to stand outside ourselves and make choices. We can choose to be caring.”

 

[Window box, Tradd Street, Charleston, SC.]

Thanks for reading Matula Thoughts this April, 2018.

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

 

Marginalia

DAB What’s New Mar 2, 2018

 

Marginalia of sorts
3732 words

 

One.

Marginalia. As a young reader I recall making casual sideline notations in margins of my books and, in time, detailed marginalia, underlining, and highlighting expanded into my college and medical school textbooks. Later, during residency I heavily personalized my pages of Campbell’s Urology trying to digest them intellectually.

The habit persists and marginal notes help make sense of what I read and leave reference points to which I can easily return. Other reading has replaced textbooks my marginalia drifted to and consolidated on end pages, creating personalized indices of page references and related comments (below “end-page marginalia” in Harari’s Sapiens).

Marginalia-making has been a human habit ever since books existed with numerous famous examples as early as amusing marginal drawings by monastic scribes alongside their serious transcriptions. A notable marginal comment unsettled the world of mathematics for nearly four centuries after French lawyer Pierre Fermat wrote in the margin of a book he was reading in 1637 that he had solved a puzzling mathematical conjecture, but claimed his solution was too large to fit the margin.

The book was a 1621 edition of Arithmetica by 3rd century mathematician Diophantus and its actual margin looks generous by my standards, although I am no mathematician. [Above: Wikipedia, public domain.] It may never be known if Fermat’s solution was correct or if he was joking, although he didn’t seem much of a jokester and his other mathematical work was accurate. Furthermore, his unsubstantiated comment was taken so seriously that it was included in later editions of Arithmetica (below: Wikipedia).

Many others tried and failed to solve Fermat’s Conjecture over the next three centuries until 1994 when British mathematician, Andrew Wiles, came up with the answer.

Scribbling in the margins of library books or books of your friends is bad form, but marginalia in personal materials conveniently identify meaningful passages or record pertinent or tangential thoughts. Some mental process pauses readers from reading long enough to acknowledge the adjacent text in some way. Marginalia are evidence of our effort to find meaning in the things we encounter.

Electronic books allow similar personalizations, although it’s not quite the same, in part because electronic screens lack the comforting tactile sense of paper. Electronic formats, however, offer new opportunities and challenges for marginalia: private marginalia can become public, aggregated, and analyzed. Audio books allow listening as we close our eyes or move physically through life, but as much as I like audio books when driving, the opportunity to make marginal notes is problematic and any spontaneous thoughts I have when hearing certain passages are usually gone from memory by the time I’ve reached my destination.

 

Two.

The compulsion to annotate or otherwise leave personal evidence of one’s presence or thought pre-existed books and is widely exercised on other cultural artifacts and the environment-at-large. Cave paintings, rock carvings, initials on tree trunks, furniture inscriptions, children’s heights on door frames, and urban graffiti are footnotes of ourselves and plant notice of us for the future. The cliché George Washington Slept Here was a 1942 play and film about a couple who moved into a run-down farmhouse (because of their dog) and they discover the first president actually stayed there during the Revolution.

The top of this posting shows a section of the Berlin Wall that faced the free part of the city, while below you see the unmarked reverse side that faced the Soviet side. These sections are on display in Washington, DC at the Newseum and were salvaged after the wall came down in 1989. The contrast is stark.

Urban graffiti, as annoying and vulgar as it can be, are an expression of personal freedom and the 45 words of the First Amendment that represents a core belief of our representational democracy.

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.”

A video display at the Newseum displays interviews on a random street showing that people are far more likely to be able to identify all the members of Homer Simpson’s cartoon family than to know the five freedoms of the First Amendment (religion, speech, press, assembly, and petition of the government). The video references national surveys that support this unfortunate observation showing 20% of Americans can recall all Simpsons, whereas only 3% know all five freedoms.

The marginalia habit fills the strong human compulsion to seek relevance and meaning, a need played out in many ways including early forms of social media content; “Kilroy was here,” “George loves Tina,” and their equivalents have been expressed by our species since the earliest human days. Graffiti as urban social marginalia, occasionally becomes valued public art such as the works of anonymous British artist known as Banksy. [Below: a Banksy image from Wikipedia.]

Historical plaques and other public commemorations are structural marginalia, we mentioned those of the old Ann Arbor Bus Station, last month, on the Residence Inn in downtown Ann Arbor. Historical markers are marginalia of place. You can find plaques at the Michigan Union on the top front landing step and on the building wall commemorating the first occasion that John F. Kennedy publically articulated the Peace Corps idea. It was during a campaign speech October 14, 1960 at around 2 AM, a remarkable time for a presidential campaign speech that highlighted the vigor of the young presidential candidate. Arriving from New York in those early hours he went directly to the steps of the Union where a crowd of around 5000 students was waiting on State Street. Kennedy began his remarks by describing himself as “a graduate of the Michigan of the East, Harvard University.” He spoke about the importance of public service, asking for young doctors and engineers, as an example, to spend a period of time in Ghana or other places. You can find the speech on YouTube and he concluded:

“I come here tonight to go to bed, but I also come here tonight to ask you to join in the effort! This university – this is the longest short speech I’ve ever made and therefore I’ll finish it. Let me just say in conclusion that this university is not maintained by its alumni or by the state merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign, I come here asking for your support for this country in the next decade.”

It was an inspiring speech. As an aside, the official portrait of Kennedy (above: painted by Aaron Shikler, whom Jackie Kennedy selected after the assassination) is on display at the Smithsonian National Portrait Gallery, along with all presidents up through Barack Obama (recently unveiled). The Kennedy portrait is the only image of a president looking down and away from the viewer, that having been Jackie’s choice.

Kennedy’s idea continues to tap into a compulsion for relevance and meaning that many students and others feel so acutely. The Peace Corps, finalized in law in the first months of his presidency, continues to resonate with college students across America. Since 1961 Michigan has been among the top four contributors to the Peace Corps with 2720 students volunteering since 1961 (after Berkeley, Madison, and Washington. [Mandira Banerjee. Feb 21, 2018. The University Record.]

 

Three.

Eleven years ago today, 2 March 2007, was the second day of my time as chair. Going to my computer I found digital images from that time in our department, including this early picture (above) of the board in my office. This has served as my functional marginalia for the Department of Urology for the past 11 years. Faculty are in the boxes on the sides and activities, units, and projects in the middle. The board changed over the years as we grew and became more complex. The picture below shows one of our visits to the billing center in the KMS Building south of I 94. Jack Cichon (now retired) was our stalwart Chief Department Administrator (CDA) and Malissa Eversole was then his understudy, having since then come into her own as our current CDA.

Below you see Ed McGuire in the center with 2 of his former fellows (now faculty) on the left (Anne Pelletier-Cameron and Quentin Clemens) plus Stu Wolf (faculty) and Walter Parker (resident) on the right.

Since 2007 the changes in healthcare education, research, and clinical delivery have been head spinning. Today the UM Medical School and health care system is rebranded as Michigan Medicine.

The time has flown by, in my mind, and if this present interval of stewardship of the Department of Urology is deemed successful in any measure, the success is due overwhelmingly to our faculty, our residents, our nurses, our physician assistants, our researchers, and our staff. Sister departments in the Medical School and this great University also account for our success; we flower in fertile soil.

This success should continue to grow with our next departmental leader whom I hope will help our clinical divisions and team do their jobs optimally, as I have tried to do. We want to avoid a repetition of the darker events of the 1990’s (as duly recorded in the Wall Street Journal and the Detroit Free Press), when Ed McGuire’s successful term and Bart Grossman’s interim stewardship were interrupted by a few difficult years until Jim Montie’s leadership brought us into departmental status and initiated the Dow Health Services Research Division. [Below: Khaled Hafez, Hugh Solomon, Jim Montie.]

 

Four.

March brings Spring steelhead to mind. It’s been many years since I’ve been on the Pere Marquette River thigh deep in waders feeling the rush of icy water working its way toward Lake Michigan. Migrating steelhead salmon, pressing retrograde to reconcile with their past, have few things on their minds at that stage and feeding is not high in their priorities. Lures need not be very sophisticated or authentic, as the fish are on their migration to spawn so they are as likely to bite out of anger or random habit than culinary urge. [Above: Brent Hollenbeck and steelhead. Photo credit: Jeff Montgomery.]

Steelhead rainbow trout (Oncorhynchus mykiss) hatch in inland streams and then swim downstream to forage in the Great Lakes (or the ocean, on the west coast) for 2-3 years. Winter-run steelhead are sexually mature and generally have a shorter run to their spawning grounds, whereas the summer-run steelhead are sexually immature when they leave the lakes or ocean and travel deeper inland. Actual spawning for either type happens in late winter or spring. These Pacific rainbow trout were introduced as immigrants from California to the Au Sable river around 1876 and after many generations are well established residents although state-managed hatchery programs supplement the existing wild fish.

Steelhead provide a loose metaphor for medical professionalism. We train our successors in the streams of academic medical centers and on maturity they go off to do their thing in the wide world. Toward the end of their careers many of them want to reconcile with their origins and travel back upstream to check out their starting points. Forgive me for stretching this analogy, but I do want to put in a plug for our Nesbit alumni, former students, and friends of the department to come back for one of our academic events, particularly in the next two years as we gear up to celebrate the Centennial of Urology at Michigan in 2019-2020.

 

Five.

Fish and urologists. Fish have twofold purposes. Primarily they pass along their DNA to their successors and secondarily they serve the larger planetary ecosystem. The optimal life span of a steelhead allows 4-6 years for one or more foraging careers in the wide world, although some Pacific steelhead live as long as 11 years and grow to 55 pounds and 45 inches, according to the National Oceanic and Atmospheric Administration (NOAA) Fisheries website.

Medical professionals have a fundamental purpose of caring for their fellow creatures, motivated by genetically crafted mirror-imaging that produced the essential human phenotypes of kindness and empathy. Secondarily, healthcare people serve their ecosystem by educating their successors and expanding the armamentarium of knowledge and technology. The career of a urologist is 40 years, give or take a decade, foraging in the real world of clinical medicine. While steelhead must adapt to gradual warming of the oceans, urologists need to adapt to rapid changes in knowledge, technology, and regulatory matters. Technology and market forces are driving changes in urologic practice at least as much as scientific evidence, leaving practitioners and patients sometimes uncertain of what treatment fits best.

 

Six.

Urologists are skilled in techniques and technology to solve urological problems but, no less than any other physicians, urologists also offer their personalities, opinions, and reassurances to patients throughout interactions that are bundled under the unfortunate label “encounters” in today’s workplaces and medical records. The language and demeanor experienced by patients often are just as meaningful to them as any treatment or technology. Indeed, the non-technical aspects of the encounter may impact the patient more than any specific medical service. This is a prime difference between the professional and a commodity natures of health care. People, as patients, treasure the right human touch.

The essential deliverable of our department is kind and excellent patient care, thoroughly integrated with education and innovation at all levels. This is not just our priority, but the priority of Michigan Medicine. Below is another picture I found from 2007 showing a faculty member and two residents who exemplified that essential deliverable back then and do so today in their new locations: Gary Faerber, now at the University of Utah; Emilie Johnson, faculty at Lurie Children’s Hospital and Northwestern Medical School; and Kathy Kiernan on the right, faculty at the University of Washington and its children’s hospital.

The human touch is also conveyed by words. A recent Viewpoint in JAMA by Arthur Barsky of the Department of Psychiatry at Brigham and Women’s Hospital is worth reading. [Barsky. JAMA. 318:2425, 2017]. The title sums it up: The iatrogenic potential of the physician’s words. Barsky invokes viscerosomatic amplification to explain how a physician can affect through words and attitude. (As is usual on these pages, we use physician as a synonym for healthcare provider.) Techniques and technology are unquestionably at the core of urologic practice, but the art of clinical practice is far more than its tools and treatments. Kindness, words, and professional touch are no less essential.

 

Seven.

Expectation. Human brains add further dimensions to medical treatments, with the matter of expectation. Every treatment carries the possibilities of real benefit or harm, but another two-edged sword exists in our capacity for imagination, something we cannot easily turn off. We may readily imagine benefit even when no physical or physiologic benefit can be explained (the placebo effect) or we may imagine elements of harm (nocebo).

Placebo and nocebo effects confound medical treatments when a therapy (legitimate or bogus, scientifically-validated or apocryphal) has a more positive or more negative effect than it rationally should have. This reflects changes in psychobiology rather than changes in physiology, pharmacokinetics, or other factors that are directly measurable or attributable to the treatment.

Nocebo, the evil twin to the placebo, is a term coined in 1961 by WP Kennedy. [Kennedy WP. Med World. 1961; 95:203, 2013.] The evil twin metaphor came from Michael Glick in an editorial in the Journal of the American Dental Association. [Glick M. Placebo and its evil twin, nocebo. JADA.2016; 147:227.] The nocebo effect occurs when negative expectation of therapy exacerbates the negative effect that the treatment rationally would cause. For some patients a given therapy, let’s say a radical prostatectomy, in addition to successfully removing a malignancy (from which direct harm might have been years away) with minimal detriment to related anatomic structures, might produce a sense of relief that carries with it additional placebo effect. For other patients a nocebo effect negatively magnifies the overall therapeutic experience and collateral damage of any attendant detriments. Every patient responds individually and idiosyncratically to an expectation and to a treatment. These phenomena, placebo and nocebo, should be anticipated for almost everything we offer in healthcare, and to the extent that we understand these possibilities and prepare patients and their families for them, we will improve the patient experience. This is one of the myriad ways that complex health care cannot be easily managed as a commodity or by artificial intelligence.

 

Eight.

As scientific medicine emerged in the 19th century it consolidated into subspecialty medicine in the 20th century and anatomic, physiologic, and microbial determinants became the focal points of healthcare. Cognitive and social factors were “marginalia” of most patient encounters. Now, in the 21st century it is clear that cognitive and social factors are equally important parts of everyone’s healthcare needs. Our profession and its business are no longer accurately described as the matter of “medical care”, but rather the matter of health care.

A prescription for a treatment or an operative procedure may be based upon symptoms and observations as entered into checklists and databases. Emotional responses and social determinants are not so easily factored in electronic medical records, particularly within the constraints of time-constrained encounters. Watson and other artificial intelligence systems are working their way into examining rooms, bedsides, and operating theaters, but these are not as effective in sensing the co-morbidities, social determinants, and other “marginalia” of the human condition, as is an attentive and kind human being. Artificial intelligence engenders great enthusiasm, but humanity should never surrender its ultimate agency to algorithms created by a self-empowered cadre of programmers.

 

Nine.

Considering gaps last month, including astronomical gaps, calendar gaps, and geological gaps, we saved an important one to mention now. A gender gap has long been present in the field of urology, although Michigan more than most other training programs began to change that imbalance, starting with Carol Bennett, who trained under Jack Lapides and was Michigan urology’s first woman graduate. Carol is now on the faculty at UCLA. In her era of training women in urology were rare. Today the situation is quite different and at Michigan we have had residency classes where women outnumber men three to one. Other years we have returned to 100% men and some year soon we could as easily have all women. In our selection process, we don’t aim for an optical effect, but rather try to pick the best talents and fits for our department from the yearly applicant cohort. Ultimately, individuals from the candidate pool make their selections when they rank the programs. [Below: Peter Knapp, Nesbit 1985 and Carol Bennett, Nesbit 1983.]

Women graduates from the University of Michigan Medical School and women trainees from our urology training program (all are considered Nesbit Alumni) are making significant impact in the world of urology, academically and in the private sector. Below you see a dinner at the recent annual meeting of the Society of Women in Urology. From the left: Cara Cimmino UMMS and faculty at Emory, Priyanka Gupta UM urology faculty, Allison (Lake) Christie Nesbit graduate and urologist in Tennessee, Miriam Hadj-Moussa Nesbit graduate and UM urology faculty, Lindsey Herrel Nesbit graduate and UM urology faculty, Akanksha Mehta faculty at Emory, Amy Luckenbaugh UM resident, and Annie Darves-Bornoz resident at Vanderbilt.)

 

Ten.

John Hall, Nesbit Alumnus 1970, wrote recently and gave me permission to give his note wider distribution here in Matula Thoughts. I came to know John after I came to Ann Arbor, largely through his high-quality practice, a sliver of which I appreciated through his pediatric referrals, as well as his local care of people I knew in the Traverse City area where he worked. Letters like his are one of the great pleasures of mine with What’s New our monthly email and it’s sibling Matula Thoughts, the web version. As we get closer to our Centennial and to reformulating our departmental history, his recollections, and perhaps yours as well, will be important to us.
From John:

“Hi Dave, I was just reading your letter of December 21, 2017. It made me think of the 5-6 doctors who staffed Urology during my training. Your staff will be limited to how many names you can put in the letterhead margin. It’s like how many doctors can fit on the head of a pin.

I finished my training in 1970, Urology 50. By 2020, Urology 100, if I’m still kicking I will be one of the few to span the history of the department. I started my contact with Urology as a student and served as a “nurse” in the Urology dialysis center. I took the vitals as the residents stirred new electrolytes into the Kolff Twin Coil Baths. As a result, I knew many of the residents from the fifties and sixties. Also, since I was appointed to residency by Dr. Nesbit, I met many of his trainees who now directed new urology departments, when they returned to AA [as visiting professors or guests], I also once met Dr. Huggins.

Dr. Nesbit retired in 1967, six months into my residency. So my group became Lapides 1. I’m not going to measure up to your knowledge of urologic history, but I am willing to provide my perspective of Michigan Urology to the Centennial Committee. Please let me know if I could provide some value to the process. Please keep writing Matula Thoughts, the highlight of my month! … John.”

Thank you, John and yes, please continue your perspectives! Much is contained in John’s brief note: the idea of 100 years of urology in AA, the imprinting of students, the Kolff “artificial kidney”,  Nesbit alum and Nobel Prize winner Charles Huggins, and the long list of chairmen Nesbit trained. Overstated only is the disproportion of historical knowledge between me and John – he knows vastly more about that midpoint in Michigan’s urologic story and I hope we can get as much as possible in print for you and others to understand our perspectives.

Since that note, John sent me a copy of his book “I’d Rather Be Sailing” and I expect to go through it and decorate it thoroughly with my own marginalia. As we reconstruct the 100-year story of Michigan Urology it will be the personal marginalia of alumni such as John Hall that provide the context, color, and personalities to illuminate the names and dates of our narrative.

 

With a few weeks until Spring, 2018, best wishes from David Bloom and Michigan Urology.

January 5, 2018

DAB What’s New Jan 5, 2018

New year thoughts
3899 words

 

One.
Dripping icicles are picturesque winter images, although this week’s massive winter storm, Grayson, extending from Florida to Maine disrupted any nostalgic thoughts of snow and ice. The icicles photographed from my study window (above) echo the pendant spikes painted by Pieter Bruegel the Elder in Massacre of the Innocents circa 1565-67.

Bruegel’s icicles (above) look charming enough, until you view the grim larger work (below – original at Queens Gallery, British Royal Collection). One broken icicle is falling in response to men kicking in an adjacent door. The actual painting has a complex history of paint-overs transforming it from grisly slaughter of babies to the plundering of a village.

So, too, the larger work of today’s climate gives the icicle a chilling perspective, as it brings to mind the Greenland Glaciers, among other melting ice forms.

Although water’s origin on earth remains controversial, water is one of the key things astronomers seek when evaluating other planets that could initiate or sustain life. Water, so central to life, is a synonym in medicine for urine, amniotic fluid, ventricular fluid, lymphatic fluid, and other waters of our bodies. Frozen water in the form of sea ice and glaciers, more or less stable for the past 10,000 years, is melting at an extraordinary rate, threatening the delicate balance of planetary life.

A startling image from the U.S. Geological Survey (USGS) website shows how little the Earth’s water  compares to the volume of the earth itself. Paraphrasing from the USGS website:

The three blue spheres below represent relative volumes of Earth’s water in comparison to the size of the Earth. In comparison to the volume of the globe, the amount of planetary water is small; oceans account for only a thin veneer of water on the surface.

The largest blue sphere represents all of Earth’s water. Its diameter is 860 miles (the distance from Salt Lake City, Utah, to Topeka, Kansas) and has a volume of about 332,500,000 cubic miles (1,386,000,000 cubic kilometers). This includes all of the water in the oceans, ice caps, lakes, rivers, groundwater, atmospheric water, and even the water in living creatures.
The blue sphere over Kentucky represents the world’s liquid fresh water (groundwater, lakes, swamp water, and rivers). The volume comes to about 2,551,100 mi3 (10,633,450 km3), of which 99 percent is groundwater, much of which is not easily accessible. The diameter of this sphere is about 169.5 miles (272.8 kilometers).
The tiny bubble over Atlanta, Georgia represents fresh water in all the lakes and rivers on the planet. Most water that life on earth needs every day comes from these surface-water sources. The volume of this sphere is about 22,339 mi3 (93,113 km3). The diameter of this sphere is about 34.9 miles (56.2 kilometers). By comparison, Lake Michigan looks way bigger than this sphere, but you have to imagine the bubble is almost 35 miles high—whereas the average depth of Lake Michigan is less than 300 feet (91 meters). [With permission, Woods Hole Oceanographic Institute. Credit: Howard Perlman USGS, globe illustration Jack Cook, Copyright Adam Nieman.]

 

Two.

Dividing human moments into calendar years, we “start fresh” each new year with renewed opportunities to explore the world intellectually and geographically. The globe of the Earth is a tool and metaphor for human exploration as well as a visual remonstration to the “Flat Earth Society.” The globes shown above are displayed in a hallway in the Harlan Hatcher Library. If you work here at the University of Michigan or even if you don’t, but happen to be in Ann Arbor and want to explore the campus, “check it out,” when you have time.

Interrogation of the moment has been a uniquely biologic phenomenon. A rock is not aware of its environment even though it is affected by it. The rock cannot consider the things around it nor empathize with whatever it may roll down upon. Our human predecessors well before Aristotle thought about matters like this (they called them metaphysical) and passed these thoughts to their successors. When language and technology permitted, these metaphysical considerations were made somewhat durable in writing.

Biology shows that humans are not unique in this capacity of interrogation, even microorganisms react and respond to their microenvironments and communicate among themselves. All biologic creatures interrogate their moments, but our species has learned to do this very well and pass along observations for future generations to consider. We do this unwittingly by epigenetic management of our DNA and purposefully through our ideas, our culture, our objects, our written language, and our sports, as seen below in interrogation of the moment by Michigan quarterback John O’Korn during Ohio State game. [From Sincock Suite. November 25, 2017. Sony 24-240 FE]

Standing at the threshold of coexistence with systems built around artificial intelligence, we are now affected by their ability to interrogate us and to increasing degrees we are transferring many decision-making powers of our human agency to these systems.

 

Three.
Imagined Expectations. It may seem premature in this calendar year to mention Abraham Lincoln. Most any month but January provides a good excuse to think about Lincoln. His birthday was in February, 1819 and next month it will be the 199th anniversary. He died in April, 1865. His most famous speech, The Gettysburg Address, was in November, 1863. What brings him to my mind just now, however, is the starting sentence of that speech on November 19: “Fourscore and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.”

Lincoln’s remarkable use of the phrase “fourscore and seven” converted a mundane metric of 87 into a poetic measure of time. He was referring to the age of our nation, but that measure of time also equates to one very fortunate human life span, although for Lincoln’s time, in the antebellum South of the U.S., the average life expectation for a white male was 38.3 and 40.5 for a white female. I couldn’t find equivalent data for other men and women of color until 1900 when it was 32.5 for males and 35 for women. All such data is a suspect approximation for reality, and means little to the particular story of any individual man or woman.

My point here, admittedly a bit strained, is that our limited personal solar cycles provide a single human the opportunity to interrogate one’s times and world, so as to navigate it well and possibly to improve it for successors. Borrowing from Lincoln, three score and ten is a more typical fortunate expectation for most of us, given the personal good luck of health, security, and opportunity that communities and governments should provide. Four score and seven is a very optimistic expectation, and for that the luck and security of health is essential.

An individual human’s expiration date hinges on genetics, luck, opportunity, choices, and the general randomness of events. For me, as a youngster growing up in the rhetoric of the Korean War, McCarthyism politics, nuclear war anxiety, air-raid drills at school, and the personal insecurity of one’s own potential and relevance, the mere idea of surviving into the 21st century seemed fanciful. Yet here we are in 2018.

 

Four.

Dee Fenner, the new chair of the OB GYN Department, is a perfect choice for Michigan Medicine (seen above with husband Charlie at autumn DEI reception). Dee is a world-renown gynecologist, a superb educator, and a first-rate administrator who has gained the respect of her colleagues at Michigan in her numerous administrative responsibilities. She also holds a joint appointment with Urology, along with 3 other members of her team. Since the days when Ed McGuire was Section Head of Urology, our departments have had a close relationship. I well remember my earliest days here when Ed and John DeLancey had a combined pelvic floor dysfunction clinic on Saturdays. Dee and I met shortly before she returned to Michigan. We were in Paris at a WHO Consensus Conference in 2001 and by coincidence found ourselves in a pen shop as the only Americans.

Words of praise are due for Tim Johnson, the outgoing chair of OB GYN and a friend of urology for the 24 years of his successive terms. Few figures in his field have generated equal respect for leadership in national and international OB GYN. His work in Ghana is legendary. Tim brought his department at Michigan into the 21st century with superb clinical divisions, excellent faculty, coveted educational programs, and worthy contributions to the knowledge of his field. Tim has been a stalwart force in the domain of women’s rights. His sense of the centrality of the essential deliverable of kind and excellent patient-centered care (if you permit me some repetitiveness) has made him a terrific colleague. His department consistently and superbly delivers its products (forgive the relevant pun).

Sad news on the recent passing of Rudi Ansbacher, emeritus professor of OB GYN and a remarkable colleague.

 

Five.
Matula Thoughts, recap. Throughout the millennia of human history clues to predict the future have been highly prized, especially so when a given future is related to health. Entrepreneurial “healers” utilized external cues from the heavens, weather, tea leaves, or playing cards to prognosticate outcomes, although the logic of using physical evidence from patients or their byproducts was evident to early practitioners. Like most other mammals, humans share the trait of personal interest in their urine, and are particularly attentive when it is abnormal during illness. Hippocratic writings documented uroscopy, as examination of urine came to be called 2500 years ago, and over the ensuing millennia the practice attained imaginative prognostications as healers examined the gross characteristics of urine in flasks called matulas to speculate on the course of an illness. The visual image of a “piss prophet” gazing at a matula served as a main symbol of physicians until only about 200 years ago when the stethoscope replaced the flask as medicine’s badge of office.

We began this electronic journal nearly 18 years ago with a respectful tip of the matula to the essayist Michel Eyquem de Montaigne who began his eclectic personal observations around 1572 at 39 years of age. That was a turbulent time, notable in Europe for the sieges of Sancerre and Haarlem, in South America for the fall of the last independent remnant of the Inca Empire, and in the heavens for the first observation of Supernova SN 1572, that Tycho Brahe gave as evidence that stars are changeable. Montaigne was likely unaware of most big events of that year, but he was certainly acquainted with physicians and matulas, given that his father purportedly died of urinary stone disease and Montaigne himself began to suffer from them in 1578.

What impulses compel us humans to foist our personal observations and thoughts on our fellows may someday be revealed through the matula’s diagnostic successors such as the MRI and other marvels of imagination, but there is no arguing that those impulses are strong and prevalent. This monthly newsletter started in Allen Lichter’s dean’s office in 2000 as a way to interact with those among our faculty willing to consider some thoughts from a colleague. Admittedly, I wrote this column called What’s New as much for myself as any potential readers, but it became a pleasant habit to send out the first Friday of each month. Becoming chair of the University of Michigan Urology Department in 2007 the monthly column transitioned to our faculty, residents, staff, alumni, and friends. What’s New has served us well, connecting us to many of our intended audience and beyond. Some recipients kindly forward What’s New to their friends, although the extent of that particular reach is mostly unknown except for occasional readers who have contacted or commented to me as a result.

 

Six.
We began a parallel version of What’s New in March, 2013, on a website labelled Matula Thoughts. This version allows us to archive the monthly columns, thereby minimizing duplication and providing the unexpected voyeuristic capability of showing the numbers and distribution of web-version readers. Likely only some of them read this carefully, while most probably glance or sprint through it. Nonetheless, the surprising numbers and distribution are evidence of the internet’s ability to connect the world. [Screenshot below – 2017 statistics page of Matula Thoughts.]

Matula Thoughts, had over 2,300 views last year, ranging from single viewers in 24 countries, 2 viewers in 6 countries, and 3 in 11 countries. Forty-one countries had 4-85 views and the US had 2364 views as of mid-December, the map showing stats for the readership in 11.5 months of 2017. It has been enjoyable to hear from, or run into, the occasional reader of the web version.

With a new chair of the Urology Department, presumably this calendar year, What’s New may be continued or another vehicle of departmental communication may be utilized, but in either case Matula Thoughts will remain in its online form (matulathoughts.org) as long as I’m able and a readership exists. These spaces will continue to be filled by matters that catch my attention and may interest some readers.

 

Seven.
Each year has a certain cadence, whether calendar, academic, or fiscal for each of the countless social and business organizations around the globe. The success of a particular person, novice or experienced citizen, in navigating the year is partly contingent on that person’s understanding of the rhythms of work and expectations of their relevant organizations.

In a clinical surgical department, the 24/7 expectations of stakeholders set the central cadence for our essential deliverable – kind and excellent patient care. The stakeholders are patients, families, trainees, staff, faculty, referring health care providers, colleagues in other departments, and the community. Around this we build our educational conferences, work schedules, training cycles, maintenance of professional certification, peer review cycles, promotional steps, reappointment sequences, and social events such as our Holiday Party that last month hosted 400 people and 115 children who had encounters and gifts from Santa. As our department has grown large this event seems to have become increasingly treasured and is the single occasion to aggregate the greater part of our complex team.

The cadence of the new chair search will capture our attention. In the case of Dee Fenner and the OB Gyn Department the process took around 6 months. Dee was the natural choice and had passed up a number of other prestigious offers from other institutions in order to remain at Michigan. At this point she is the only other chair here to have a joint appointment with our department.

 

Eight.
Breakthrough of the year. Science, the AAAS journal, began a feature called Molecule of the Year in 1989, following Time Magazine’s Man of the Year that had started in 1927. Wikipedia relates that Time’s cover was originally a response to its embarrassment earlier that year in failing to put Charles Lindbergh on the cover following his trans-Atlantic flight. As the Man of the Year expanded to including all persons, as well as groups (in 1960 it was U.S. Scientists), ideas, or objects, so too did the Molecule of the Year to become the Breakthrough of the Year.

Science named the observation of cosmic convergence, a violent merger of two neutron stars on 17 August as the scientific breakthrough of 2017. Runners-up included cryo-electron microscopy observations on organic molecular function, thermoluminescence dating of early human roots, pinpoint gene editing techniques, preprint sharing in life sciences, FDA approval for checkpoint inhibitors, discovery of a new living species of Hominidae (the Pongo tapanuliensis orangutan), recovery of 2.7 million-year-old ice cores that contain ancient atmosphere (with CO2 levels under 300 ppm), and successful gene therapy for spinal muscular atrophy 1. Once again, biology dominated the main scientific achievements of the year.

 

Nine.

Disclaimer. Because of a few skunks in academic medicine, speakers at nearly every medical presentation around the world declare absence, or occasionally presence, of “conflict of interests.” Mostly these are silly declarations, and effective skunks either lie or mislead audiences with their declarations. It is easy to mislead others, because all social transactions, especially those in health care and in academia, are built on trust.

The necessary velocity and fluidity in science and medicine preclude extensive authentication and verification in real time. For example, when a colleague tells you that a serum creatinine is 0.8, you accept that as fact. Mistakes may happen in our workplaces, but they should sharpen our attention to truth and not let false facts become a way of life. Once, however, deliberate lies or plagiarism are revealed trust should never easily be restored. The cutting and pasting that has become so easy, indeed almost necessary, in the modern electronic medical record allows a very seamless slip from mistake to deceit, once a clinician starts to lose the sense of individuality of patients. When a physician loses that appreciation of the uniqueness of a patient, a history and physical for, let’s say a boy with undescended testicle, can be “generalizable.” Checking off a few boxes, or even cutting and pasting an entire H&P, is certainly more efficient than asking questions, observing the patient and family, and examining the child. This is akin to Paul Simon’s cynical song, The Myth of Fingerprints.

Another associated, yet perhaps minor, gripe I have with the EHR occurs in the operating room, when at the end of a procedure in the well-intended, but tedious “time out” I am asked to describe the blood loss. My claim of “minimal” is always rejected because the computer only allows a number. In many cases a tiny bit of red can be seen, but is it 0.5 ml or 5.0 ml? It is somewhere in that range, but unmeasurable, insignificant, and inconsequential. When I am asked to fabricate a number, my mind rebels and when I do come up with a number it feels more like a lie than a guess.

Anyway, with the start of a new calendar year I thought a disclaimer would be useful. Therefore, let me state that I seem to have no conflict of interest or conflict of commitment that would steer the comments in What’s New/Matula Thoughts to any drug, product, political party, or ideology outside of belief in liberal democracy (life, liberty, and the pursuit of happiness under representational government), public education, planetary conservation, social justice, and The University of Michigan. The thoughts herein, unless authorship is otherwise specified, represent mine alone. I don’t necessarily speak for our Department of Urology, Michigan Medicine, The University of Michigan, the State of Michigan, the United States, or the United Nations.

Hoping you are comfortable with these statements, I invite you to peruse, delete, comment upon, or forward What’s New (the email version) or Matula Thoughts (the web-site version) this new year of 2018. What’s New is a hint that we offer some news from our academic department and health center. Matula Thoughts is a term that hinges on an ancient symbol of the medical profession that was a transparent flask used to examine urine, one of the few clues to disease that ancient caregivers had available. The matula was replaced by Laennec’s invention of the stethoscope in 1816 in Paris, but both tools reinforce the threatened idea that physicians should look at and listen to their patients.

 

Ten.

 

The new year, 2018, began with Michigan’s appearance at the Outback Bowl in Florida four days ago and many red moustaches and haircuts in support of the Chad Tough Campaign for brain tumor research.

Alon Weizer is Acting Chair of our department for the next three months. This cycling of our associate chairs has been healthy for the department and for me. During this time I’ll be working on the UMMG Bylaws, helping re-activate our Michigan PAC, laying out plans for our centennial, and continuing some development efforts, and remaining active with the Hamilton Community Health Center and its board.

Some people have queried the administrative structure of our department. Our basic backbone is the Senior Clinical Management team, composed of our division heads, our residency program director, and our peer-review quality officer. The associate chairs have responsibilities that transcend divisions, for example the research portfolio, faculty affairs, operating room distribution, in-patient clinical operations, and ambulatory care management. Our ultimate responsibility, day-in and day-out, is the essential deliverable of kind and excellent patient care. Michigan Medicine, our other departments, the community, referring physicians, and the University of Michigan depend on our ability to do this very well. This essential deliverable is also our primary financial engine, as we defend and expand our markets. It should go without saying that these markets are clinical, educational, and academic markets.

We have been fortunate over the past 2 decades of Jim Montie’s and my terms in delivering our particular essential deliverable and in defending and expanding our markets. Few could find major deficits in those regards, as our external review by Mark Litwin, Ed Sabanegh, and Bradley Leibovich pointed out recently. However, the waters ahead will be turbulent and we will need a steady and resourceful hand who enjoys the support of our faculty.

This winter, a search committee convened by our deans is in the process of finding candidates for leadership for our department. Having experienced one disastrous change of leadership for Urology after Ed McGuire left us for Texas in 1992, we are aware of the risks of change, but our deans and the search committee at hand give us confidence in a good outcome. With superb division heads and associate chairs in place we have a very strong and deep bench. If there is a better external candidate on the planet, good for us, but it would be hard to beat our bench.

I don’t think I’ve left too many administrative problems for Alon, after all we have finished our main work of the cycles of reconciliation of FY 17 and planning for FY 19, on-boarding of new faculty, academic promotions, and residency recruitment. Alon will oversee the daily operations and occasional crises inherent to any business with several hundred employees, clinics at 16 sites, surgical teams at 9 locations, training of 28 residents and fellows, six separate investigative teams, etc.

Our new relationship with West Shore Urology in Muskegon has energized us and created a new reach to the west side of the state. The growing relationship with Mid-Michigan and with Metro Hospital also offer great opportunities. Our efforts with the Hamilton Community Health Network in Flint continue as well, and I’m especially grateful to members of our urology department and a few other UM departments who have participated in this important connection.

A busy year and a half lies ahead. In February we should hear the names of the new resident trainees to join our department. Our Departmental Retreat, April 14, will take stock of where we stand and where we are headed. The Teeter Symposium, May 4, will survey our work with bladder cancer. The Nesbit Alumni Reception at the AUA will be held on Sunday May 20 in San Francisco. During the Art Fair Season the Chang Lecture on Art and Medicine July 19 will inaugurate a new residency training season. The next day Hadley Wood of the Cleveland Clinic and Rosalia Misseri of Riley Children’s Hospital in Indianapolis will be the Duckett and Lapides Lecturers. The biennial Dow Health Services Research Symposium will take place September 13 and 14. Our own alumnus, Toby Chai of Yale University, will be Nesbit Alumni Visiting Professor September 20-22. The Montie Uro-Oncology Lecture is planned for early 2019, and later that year we will begin our Urology Centennial Celebrations to transition into the second century of urology at the University of Michigan, under improved new management, by then.

 

Thank you and Happy New Year from the Department of Urology of the University of Michigan.

 

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

Transitions.

DAB What’s New Dec 1, 2017

3818 words

 

One.

The Michigan Theater, seen above on a crisp autumn evening, is one of Ann Arbor’s many delights, making it easy to “sell” our town to medical students who interview for urology residency. Reflecting the halcyon days of motion picture palaces, the theater opened January 5, 1928 with grand lobbies, 1700 seats, a Barton theater organ, and an orchestra pit. Now, after ninety years of capital campaigns and restorations, the building has three auditoriums and is the center of the Michigan Theater Foundation, a world-class non-profit center for fine film and other cultural events. Its State Theatre, across the street, reopens this month after a well-earned renovation. Michigan Theater hosts the Ann Arbor Symphony Orchestra, Cinetopia International Film Festival (in partnership with the Detroit Institute of Arts), organ concerts, and other live-stage events. When days in the next few months get gray, slushy, and cold, the Michigan Theater is a wonderful refuge and it’s equally delightful the rest of the year.

“I’ve seen this movie before” is a phrase in vogue for recurrent phenomena and so it seems with the autumn ritual of residency applications. Fourth-year medical students travel around the country as “sub-interns” to audition at training programs in hopes of securing 5 to 6-year residency slots. Yet, every annual cycle presents a unique array of new faces, talents, experiences, and energies of candidates visiting our Ann Arbor program. This recruiting season has been particularly good, marked by nearly 70 astonishing medical students who interviewed for four residency positions to start here on July 1, 2018, as the class of 2023.

Just as we rank the students, they rank us among the other programs they like and a computer makes the binding national match. Most applicants we see will become successful urologists and most programs they rank will train them excellently, evidence that our medical schools and professional organizations have created high standards, with narrow Gaussian distributions of quality. This is to say, the very best programs and candidates falling on the right side of the curve are not grossly dissimilar by most measures from the programs and candidates on the other side. A theoretical program variability curve (blue) and wider student applicant curve (red) illustrate my belief that some applicants are potentially “better” than any of our programs. That should be no great surprise, as it indicates Darwinian principles at work: some of our successors should, by all rights and intents, surpass those of us who teach them.

“`

 

Two.
What does it take to go from applicant to successful resident? Most people we interview will become excellent residents and urologists who will impact their communities and practices significantly, and some will advance the field of urology in major ways. Before students create their preference lists, they need to get in the door for rotations and interviews. This requires good Step One board scores and excellent medical school performance data. Since most schools are “pass-fail,” applicants must demonstrate noteworthy performance in their clinical clerkships, such as “honors” in their deans’ summaries and strong letters of endorsement. When recommendations come from colleagues we know, with good track records of producing students who become excellent residents, we pay attention. Honorary society membership, selection to AOA for academic work or the Gold Humanitarianism Society, helps demarcate successful applicants. Exemplary social behavior is an important feature and successful performance on teams, such as college sports and humanitarian efforts, is also typical of our applicants.

Test metrics, honors, and accolades are surrogates for the attributes we seek in our residents and future colleagues. We want individuals with intellect, empathy, ingenuity, resilience, and good humor. Good residents and good colleagues tolerate personal inconvenience to help their patients and teams. Particular metaphors illustrate our affinities. The people we seek have the “fire in the belly” to do the daily work and to solve meaningful problems. They “go the extra mile,” or add-on the “extra case” at the end of the day when the going gets tough. We need people who work well in teams, yet are effective leaders when the opportunity or need arises. Candidates similarly seek attributes of training programs. Surveys and “field notes” over the years identify important factors in play for applicant preferences such as program depth, established mentorships, institutional culture, geography, global opportunities, and climate.

Two new features of our program will come on line. Steve and Faith Brown of California created a scholarship for a medical student, preferably from UM, entering our urology residency each year. The Brown scholarship will help residents with research projects or unique educational experiences. An intermittent 5th residency/research position, intended for a physician-scientist and established with the NIH and AUA, will start in 2019 and last seven years.

 

Three.
The Gaussian distribution of residency programs, narrow and steep, reflects the fact that nearly all are fully capable of preparing trainees for excellent urologic careers. The wider applicant curve reflects my belief that many of our trainees have the capacity to be better than we (the faculty) are now. In fact, this is our goal. We want to train residents who will leverage the best of what they learn and see from faculty today to improve urology practice and research throughout their ultimate careers. In their own time, today’s residents and fellows will discover new knowledge, recognize new paradigms, invent better technologies, create novel operative solutions, and find ways to deliver health care more safely, efficiently, generously, equitably, and with greater kindness. If we do our work properly, our trainees will be more adaptable and creative in the environments of their tomorrows, than we could be if we cloned ourselves.

Johann Carl Friedrich Gauss (1777-1855), the only child of a poor family, was born and raised in the Duchy of Brunswick, now Lower Saxony, Germany. A child prodigy, he attracted the interest of the Duke of Brunswick who supported his education locally and at Göttingen University. Gauss’s doctoral thesis in 1797 offered a proof of the fundamental theorem of algebra, that every polynomial equation with real or complex coefficients has as many solutions as the highest power of its variable. The duke’s philanthropic investment paid off well, as Gauss became known as “the foremost of mathematicians” (Princeps mathematicorum) and the most influential mathematician in the past millennia, impacting numerous areas of mathematics and science in general. Many echoes from Gauss’s brain reverberate today. In addition to Gaussian distribution we have the Gauss unit, Gauss law, Gauss formula, Gauss platform, Gauss elimination, Gauss-Bonnet theorem, and even the Gauss rifle. The web reveals an astonishing array of Gauss’s quotes, revealing a humorous and humanitarian mind. (Below: Daguerreotype of Gauss on his deathbed. Wikipedia.)

 

Four.
Universities are civilization’s best bet for its future, teaching tomorrow’s citizens and builders, and expanding today’s knowledge. Universities explore “the nature of things” and public universities play a particularly important role. A quote by David Damrosch stays with me:

“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 (Three Thousand Futures).” [Damrosch, D. We Scholars. Harvard University Press. 1995, p. 18.]

Purposeful building of successive generations cannot be left to chance or entirely entrusted to government, religious entities, or the private sector. Nor should this be entrusted to any single university system, whether state or private. A diversity of universities, public, private, and ecclesiastical (in collegial or sometimes sharp competition with each other) will be the best way to educate successive generations, innovate technologies, and create and test new ideas for tomorrow. Universities must accommodate the immediate milieu and stakeholders of today, while taking the long view for subsequent generations. Gauss’s university is exemplary.

The University of Göttingen was founded by King George II of England in 1734 (as Elector of Hanover) and quickly became a center for the nationalistic reawakening of the German lyric and national poetry.  Encyclopaedia Britannica credits the university with releasing Germany “from the confines of the rationalism of the Enlightenment and from social convention.” Gauss studied at Göttingen from 1795 – 1798, but around its centennial in 1837 the university took a reputational hit when seven professors were fired for political unrest. Luster was restored before its bicentennial particularly at its Mathematical Institute, that Gauss had once led. Göttingen has produced 40 Nobel prize winners including Max Born, James Franck, Werner Heisenberg, and Max von Laue. The strong mix of humanities and science at the University of Göttingen is noteworthy evidence that these two facets of creativity are inseparable, divided only by parochial and unimaginative perspectives. A century younger than Göttingen, The University of Michigan is no less rich in humanities and science. All universities need to figure out better ways to merge those two fundamental sides of knowledge.

 

Five.

Galens 91st annual Tag Days began yesterday and will run through tomorrow. Medical students and faculty at the University of Michigan created Galens Medical Society in 1914 for student advocacy and as a social bridge between students and teachers. The name choice is both obvious and obscure. Galen was one of the early great names in medical practice and study, but it remains a mystery as to why that particular name was selected for this medical society. Galens Society at Michigan created an honor system, obtained secure student lockers (theft was a problem even in those halcyon days), and established a student lounge. In 1918 Galens members held the first Smoker, a series of skits performed by Galens men. Galens shifted its focus in 1927 to raise money for children with Tag Days, wherein students solicited faculty and community members, a tradition that continues the first weekend of December in the Medical Center and the streets of Ann Arbor. The Silver Shovel Award began in 1937 to honor faculty who have shown extraordinary commitment to teaching medical students.

At some point Galens opened its doors to women medical students, reinvigorating the organization. Galens initiated the Mott 8th floor project in 1964 to house its Workshop for Children that had been ongoing since 1928, but lacked a permanent site. A chapel and student lounge were also created in that space. Galens contributed funds for the Mott Pediatric ICU in 1968 and in the 1980s made a similar contribution to St. Joseph Mercy Hospital for its Pediatric ICU. In 2006 Galens came up with $200,000 for the Child and Family Life Playrooms in the new Mott Hospital. In addition to the Mott Child and Family Life Program, Galens has supported Ozone House, Foundations Preschool, Children’s Literacy Network, The Corner Health Center, and Special Days Camp, among other worthy projects.

Galens today includes about 120 medical students and 13 honorary faculty members. During Tag Days students on street corners sell tags that raise nearly $100,000 for Mott efforts and other children’s programs in Washtenaw County. In addition to The Smoker, Galens supports a Welcome BBQ, a tailgate, and a year-end banquet. A Galens Loan Fund helps medical students for their interviewing costs, that easily can cost students $5,000 – $10,000 as they travel around the country in their fourth-year interviewing for residency. Next year’s Smoker, by the way, will be March 2 and 3 at Lydia Mendelssohn Theatre.

 

Six.
Michigan men.

Francis Collins returned to Ann Arbor last month for the M Cubed Symposium and gave an inspiring talk that he called “NIH: National Institutes of Hope.” As a faculty member here in the Department of Human Genetics, his team figured out the genetic basis of cystic fibrosis. He went on to co-direct the human genome project and is currently NIH Director. Collins spoke about the considerable footprint of UM in medical research and our relatively large portion of the NIH budget.

Dr. Collins offered three reasons for splicing “hope” into the NIH acronym. First is the role of the NIH in uncovering life’s foundations; second is the NIH intent to translate discovery into health; and third is the synergy in the socialization of science, that is the idea that collaborations are the best way for the scientific community to “move forward, together.”

The NIH origin dates back to July 16, 1798 when Congress established the Marine Hospital Service “for the relief of sick and disabled Seamen,” recognizing that their healthcare was a responsibility of the government. The Marine Hospital Service fell under the Treasury Department and a monthly tax of twenty cents was deducted from the pay of merchant seamen, making this America’s first prepaid health care system. Less than a year later, legislation extended the benefits of the Marine Hospital Service to Navy and Marine Corps personnel. In 1875 a new law directed the President to appoint a Surgeon General of the Marine Hospital Service with advice and consent from Senate. Interstate quarantine authority was granted by Congress in 1890. The name of the service was changed in 1902 to the Public Health and Marine Hospital Service, eventually growing into the NIH, now intended to improve knowledge and extend services to improve health. The current budget exceeds $32 billion.

John Park was recognized as Clinician-of-the-Year at the Michigan Medicine Awards Dinner last month. A superb pediatric urologist, quintessential teacher and mentor, and leader as Surgeon-in-Chief at Mott, John is one of the most respected and beloved clinicians of Michigan Medicine. The yearly awards celebration was instituted by former dean Allen Lichter, continued by Jim Woolliscroft, and now is fine-tuned by Marschall Runge, Carol Bradford, Bishr Omary, and David Spahlinger. (Below: Park family)

 

 

Seven.
When calendar years close out, pundits tally major events and accomplishments, as if to predict what future generations might mark as notable for that year. Some events and findings this year, unrecognized by most of us likely will rise to great significance in future times. At this moment, as of December first, some breakthroughs of the year are already acclaimed as important, although much can yet happen for good or for bad this last month of the year.

Science magazine traditionally announces its “breakthrough of the year” with 9 runners-up, as a result of a “people’s choice” poll. Likely contenders for that list will be: observation of gravitational waves by three separate observatories, thereby supporting Einstein’s general relativity theory; CRISPR gene-editing to correct the mutation causing hypertrophic cardiomyopathy in a viable human embryo (similar work was reported in China a few years ago); neutron star collision (kilonova) witnessed at LIGO; and human-pig hybrid creation at Salk.

Editors and writers of Science magazine in 2016 picked the detection of gravitational waves as the breakthrough of the year announced in the December 2016 issue [Adrian Cho. The cosmos aquiver. Science. 354:1516, 2016]. Alternatively, another poll (of readers) listed the gravitational wave by the LIGO interferometer as number two, preferring as number one the breakthrough in tissue culture techniques that allow human embryos to be sustained ex vivo for nearly 2 weeks. The “people’s choice” for number 3 was portable DNA sequencers, followed by an artificial intelligence milestone for number 4, and a finding on cell senescence and aging. My point is that human biology was central to 4 out of 5 of the 2016 breakthroughs and will likely be prominent in the 2017 choices.

 

Eight.
December first, looking back, is noteworthy for historic airplane crashes. As the methodology of aviation checklists has been imported into medical practice, most visibly in the surgical arena, it is useful to cross-examine failures and successes in both fields. Two aviation disasters occurred on this particular day in 1974. TWA 514 crashed northwest of Dulles Airport killing all 92 on board. En route from Columbus to Washington National Airport (now Reagan) the plane was diverted to Dulles due to high crosswinds and slammed into the west slope of Mount Weather. Terminology discrepancy between flight crew and controllers, heavy down drafts, and reduced visibility from snow were blamed. U.S. Congressman Andy Jacobs, scheduled on that flight, had refused to pay a $20 seat upgrade and luckily took another plane. The same day, Northwest 6231 crashed near Stony Point, NY, killing only the three crew members flying the plane from JFK airport to Buffalo as a charter to pick up the Baltimore Colts, whose planned aircraft was grounded in Detroit by a snow storm. Failure to activate the pitot tube heater, presumably a checklist item, was the root cause, resulting erroneous airspeed readings, icing, and a stall. Both planes were Boeing 727s.

On this day in 1981 Inex-Adria Aviopromet Flight 1308, a Yugoslavian charter McDonnell Douglas MD-81 from Brnik Airport in Slovenia, crashed on approach to Ajaccio on Corsica. Air traffic control believed the plane was in a holding pattern over the sea and requested it to descend, although it was actually 9 miles inland. The crew knew the plane was over the island and was surprised at the instruction to descend from their holding pattern, repeating their uncertainty to ground control. Ajaccio Airport had no radar and flight controllers insisted on descent which took the plane right into Mont San-Pietro killing all 180 people on board. On investigation, communication confusion was named as main factor.

Coincidentally a few years later, on this particular date in 1984, NASA conducted the Controlled Impact Demonstration at Edwards Air Force Base, deliberately crashing a Boeing 720 flown remotely so as to study occupant crash survivability. (Picture below, Wikipedia.) Planes seem to be made more safely, but the human factors of miscommunication and deviation from routine procedure remain our Achilles heel.

 

Nine.

As the urology chair search process unfolds many people will be engaged in trying to figure out the best fit for our department. Academic medicine seems to have convoluted the process of leadership succession, but it need not be difficult. A reasonable chair candidate should be someone who can take a team from good to great. A good candidate has a track record of excellence and national respect in his or her field, particularly in the essential deliverable of the department. Chairs who have failed nationally never passed these two bars.

The key requirement of a chair is to deliver the main functionalities of the department and enhance its essential deliverable. For us, that key deliverable is state-of-the-art clinical care in all domains of urology and with accessibility for anyone in Michigan or beyond who seeks our services. The essential deliverable is the milieu for our foundational responsibility of educating the next generation of urologists and urology health care workers trained in urology. The essential deliverable is also the stimulus and laboratory for our mission of discovery and research. A chair must retain and recruit excellent faculty and staff to build stability and depth of the department’s critical units, while helping its people develop their careers and fulfill their aspirations.

Personal traits of kindness, moral center, integrity, trustworthiness, flexibility, high emotional quotient, and humor are important. These are difficult to ascertain in external applicants, while a few minor deviations noted over decades of interactions “in the trenches” can derail internal candidates. Intellectual ability to deal with stress, complexity, and ambiguity is necessary. A successful chair needs curiosity to keep up with urology, medicine in general, and the changing world as he or she guides a department. A personal sense of cosmopolitanism builds the diversity, equity, and inclusion necessary for a great team.

A number of organizational talents are critical. The chair must understand and articulate the mission of the organization, sharing its beliefs and values. The chair must listen well and understand the department’s stakeholders. The chair must build teams, develop consensus, elicit a vision, and craft strategies with stakeholders. The chair should be a proven hands-on problem solver when necessary, yet be an excellent delegator. The chair must understand the social responsibility of the organization relative to its partners, community, region, nation, and world-at-large. A chair must steward and grow the departmental resources. I came to learn these attributes from leaders of my various career stations and particularly from dean Allen Lichter and coach David Bachrach.

 

Ten.

What lies ahead. It may seem doubtful that many people will be talking about “the halcyon days of 2017” next year or beyond, yet who knows what lies ahead to reframe our perspective? Historians viewing certain domains such as Astros baseball, might indeed think 2017 was a golden, happy, and joyful time. Turbulence in the health care markets, the uncertainties of regulations such as MACRA, changing demographics, expanding comorbidities, domestic violence, and environmental deterioration may combine to make 2017 look better from the rear-view mirror than it seems now from our perspective in December of this year.

Secular stagnation, an idea proposed by American economist Alvin Hansen in 1938, suggested that economic progress after the Great Depression was restrained as investment opportunities were held back “by closing of the frontier and collapse of immigration” [Economist Aug 16, 2014]. The idea could be expanded to the thought that any great shock to the world-at-large is followed by a period of latency. One can only guess how historians someday will define the era in which we are presently immersed. Stagnation of human progress is evident in many parts of the world, encompassing diplomacy, human rights, food security, personal safety, health care, environmental quality, as well as economic growth. If one views the world through a dystopia lens, then tomorrow’s metaphorical glass is half empty and this year may be viewed as relatively halcyon. With a more optimistic lens, if human progress ultimately wins the day, as history indicates, the year 2017 may not appear particularly halcyon.

This year ahead will be busy for the Department of Urology at the University of Michigan. A search committee for new chair begins with strong representation from our department. John Wei, Kate Kraft, and Scott Tomlins know our department well, and the other members of the committee are terrific choices as well. Our departmental retreat, April 14, will be a good time to take stock of the process. A special meeting on bladder cancer, the Teeter Symposium, is planned for May 4. Bob Teeter, a friend of our department, lost his life to bladder cancer a decade ago and since then knowledge of the biology of this disease had advanced greatly, as have surgical and medical treatments. The symposium will be an opportunity to see how far we have come and develop some paths for the future. We look forward to the Nesbit Reception at the AUA in San Francisco, Sunday, May 20. During the Ann Arbor Art Fairs, we will host the 12th Chang Lecture on Art and Medicine on July 19 and the next day will feature Hadley Wood of the Cleveland Clinic as the Duckett Lecturer and Rosalia Misseri of Riley Children’s Hospital in Indianapolis as the Lapides Lecturer. Our Health Services Research Symposium will be September 13 and 14. The Nesbit Alumni Society meeting September 20-22 will feature our own alumnus Toby Chai, now professor of urology at Yale. The Montie Uro-oncology Lecture is planned for some time next autumn. In 2019 we begin centennial celebrations to transition into the second century of urology at the University of Michigan.

 

[Neighborhood leaves, in transition, 2017]

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