American Urological Association

Quilting bees and blues

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WN/MT October 2, 2020
Quilting bees and blues
2392 words

One.

 

 

 

October Blues. Historically at this time of year, the blues came from regret over the loss of summer and the expected hunkering-down for winter ahead in the northern hemisphere. October 2020, however, finds most of the world already hunkered down for Covid-19. Students had another cause for October Blues, after the emotional rush of new school terms in September gave way to the “boring” routines of schoolwork, boredom that is now a matter of fond nostalgia.

No one can reasonably deny that schooling is essential to pass along skills and knowledge to successive generations. The processes and environments of schooling, in all its forms, also provide opportunities to improve the actual knowledge and skills, as well as forge community values. The present pandemic reaffirms that schools are a cornerstone of society at K-12 levels for socialization of students and for liberation of parents to do their daytime work. Higher education and the myriad forms of schooling beyond traditional schools are no less essential, but sharply compromised by pandemics that, recurring as we know well, should not take us so completely by surprise.

The Quilting Bee (above) shows a community passing along skills, knowledge, and values through an organized tradition. The painter, Anna Mary Robertson “Grandma” Moses (1860-1961), started to paint seriously at age 78, completing The Quilting Bee in 1950. Quiltmaking and quilting bees, also called quilting frolics, were good ways for communities to dispel their situational blues. Quiltmakers have transcended cultures from the earliest known quilts around 3400 BCE in the Egyptian First Dynasty to more recent times in this country. Enslaved Africans, New England Quakers, Hawaiian natives (shown below), and Amish communities in Pennsylvania, Ohio, and Indiana, among countless others, developed quilting expertise, passing along methodologies, and improving the art across generations. [Niihauan quiltmakers, photograph by Francis Sinclair, 1885, Wikipedia.]

 

Stephen and Faith Brown, UM alumni and friends of the Urology Department, followed their serendipitous interest to become expert collectors of Amish quilts, exhibiting their quilts at the UM Art Museum, the Renwick Gallery, the University of Kansas, the Denver Art Museum, and the de Young Museum. The unexpected bold colors and patterns of those quilts contradicts the restrained lifestyle of the artisans and surely must have dispelled their blues while enhancing their sense of community. [Exhibit at Renwick. Copyright Faith and Stephen Brown.]

 

 

 

Two.

 

Succession and success. Skills, arts, and knowledge of quiltmakers, soldiers, archeologists, urologists, and other workers of all sorts survive only through their successors. Virtually every discipline ensures its succession through role-modeling, education, and training, prospering when the processes of succession are deliberate.

At this time of year, medical students are anxiously sorting out their career paths and seniors are taking specialty rotations and applying to training programs. Last year’s seniors are now residents-in-training at Michigan Medicine in the fourth month of what was once called “internship,” currently labeled postgraduate year one (PGY 1) in the jargon and long line of continuing medical education (CME). [Above: Terra Cotta Soldiers of Qin Shi Huang, first Emperor of China, c. 210 BCE. Below: successive UMMS class pictures in UH corridor.]

 

The Department of Urology, as any recruiting discipline, has the double duty of selling itself to applicants while also appraising them for abilities to succeed in training and practice. Equally important, we want to build our team in urology while enhancing its diversity. We have a strong track record in this work from the days of Program Directors Gary Faerber and Khaled Hafez, and currently Kate Kraft and Sapan Ambani (all shown below).

Gary Faerber (Nesbit alumnus 1989 – now a professor at Duke.)

 


Khaled Hafez (Nesbit alum 2004)

 


Kate Kraft (Nesbit faculty 2011)

 


Sapan Ambani (Nesbit alum 2014)

 


We had no idea, last year at this time, that interview days wouldn’t take place as usual this season, when digital surfaces will reduce the full human dimensionality day-long experience to constrained transactional computer sessions. Zoom will dominate until society-at-large equilibrates with Covid-19 so we can resume a more human interview process.


Three.

Hopes and dreams. What do residency applicants want? Overall, they want a five-year learning and living experience that will bring them happiness and success, although each individual defines these conditions uniquely.

What do the faculty, current residents and fellows, and staff want? They want bright, industrious, and dependable learners and workers who will be successful in their training and in their careers. From its start in the 1920s, UM Urology has trained people to advance the discipline through care of patients, creation of new knowledge, and teaching of sequential generations. Shared values of integrity, kindness, leadership, and citizenship have been modeled and reinforced in our community of work and learning for nearly 100 years.

For the many applicants to UM Urology, we can offer only a few positions. Selection is necessary, but identification and ranking of top applicants is painfully imprecise. Applicants similarly need to assess the training programs in the national match process and for them as well, no ideal formula, algorithm, set of experiences, or scores, predicts success. Guidance from “experts” at gauging successful outcome is a forlorn hope and appraisal by each party comes down to personal holistic consideration, that is gestalt. During recruiting seasons as department chair, I wished we could have taken many more applicants, as I saw potential for success in training and in life within most candidates. While the matching process is currently an embarrassment of riches for training programs, it is a matter of life-altering consequence for each applicant.

 

A painting in 1886 called Hope by George Frederic Watts (1817-1904), captures the complexity of the predicament: a blindfolded woman sitting on a globe plays a lyre with only a single string remaining. Possibly she retains optimism in spite of obvious handicaps. Perhaps she is content but realistic. We can only guess the artist’s intent, but regardless of the nature of her thinking and sense of hope, the scene certainly is suffused with the blues. [Above: Tate Museum].


Four.

Prediction. The UM Bentley Library contains great riches – we have seen this in our study of the UM Urology history. One exchange of letters between UMMS Dean Victor Vaughan and a physician in Marion Ohio, named Fillmore Young, in July 1919, centered on the question of “Why some succeed, while others fail” in medicine. Young intended to give a paper on the topic and wrote to Vaughan, as “one of about fifteen of the prominent men of our profession who have succeeded,” asking for three indicators of success. As an example, Young quoted three predictors from the prominent American surgeon, Nicholas Senn (1844-1908).
“First: He knew his business.
Second: He asked no outside advice.
Third: He demanded his position.”

Senn’s dogmatic, inflexible, and self-assured advice was ridiculous, largely the antithesis of any responsible advice for success. Vaughan’s reply (shown below) revealed a greater mind and kinder person.
“Dear Sir;
In my opinion, there are three qualifications essential to success. The first of these is intelligence; the second is industry and the third is integrity. Fortunately most men are born into the world with a good degree of potential intelligence. They are furnished with a normal brain and they only need to work it right and with sufficient industry. Intelligence and industry, however, in order to lead to real success must be controlled by integrity,
Yours truly, Victor C. Vaughan.”

 

Dean Vaughan wrote this just a month after learning of the death of his oldest son, in France at the conclusion of WWI. This was also when Vaughan first considered Hugh Cabot for the chairmanship of the UMMS surgery department, and in whom the qualities of intelligence, industry, and integrity seemed to be in full display.


Five.

Opportunity. One year after this exchange of letters, when the only gender qualified for success in medicine seemed to be male, the 19th Amendment to the Constitution legislated voting rights to women. This doubled the American voting denominator and helped open up the national talent pool for work, ideas, and leadership necessary for society.

While the University of Michigan and its Medical School had been educating women since 1870 and 1871, the numbers of women in the classes, never at parity from the start, sharply dropped off in the first half of the 20th century and only reached parity in the early 21st century. The inclusion of women in medicine doubled the talent pool for medical progress.

More recently, one hopes, the George Floyd tipping point signals a groundswell of sentiment to deconstruct widespread structural racial impediments to equal opportunity for all people to pursue success.
In case you missed Randy Vince’s article, “A piece of my mind: Eradicating racial injustice in medicine,” in JAMA last month, it’s well worth reading. [JAMA, 324:451, 2020.]

 

Randy, our senior uro-oncology fellow, offers a personal perspective, referring to stages of learning in the transition from ignorance to mastery of a subject. He suggests personal steps to ameliorating social injustice, and the final one, implementation of widespread culturally-aware mentorship training, is predicated on the idea of building pipelines of opportunity for as wide a swath of the human talent pool as possible. This is a matter of widely seeking and extending mentorship throughout all communities of our potential successors. Of course, no single health care provider can mentor every possible community, but a robust team such as UM Urology can probably cover most. [Above: Vince at a socially-distanced coffee break, September 2020.]



Postscript.

Purposes and cross purposes. Higher education is in the news this month, as never before and institutions that figure out how to bring students and teachers together in safe proximity will be highly prized. Hand hygiene, face masks, and social distancing work well. It shouldn’t be rocket science to outfit some classrooms and lecture halls as “test kitchens” with vertical laminar air flow. The reversed air flow need not be “ICU grade,” but just enough to give gravity a little help with respiratory droplets. It would be money well-spent, for this will not be the last pandemic to interrupt educational routines.

Students come to colleges, universities and medical schools for a number of purposes, sometimes cross-purposes. Some want to learn who they are and understand their place in the world. Others seek knowledge and skills, or merely a ticket, to a particular occupation. Many students are deeply curious about a particular subject. No small few simply want liberation from home and opportunities for socialization. Schools, for most students, are a means to some end. G.K. Chesterton, mentioned in these columns last month, once wrote:
“ … in logic a wise man will always put the cart before the horse. That is to say, he will always put the end before the means; when he is considering the question as a whole. He does not construct a cart in order to exercise a horse. He employs a horse to draw a cart, and whatever is in the cart. In all modern reasoning there is a tendency to make the mere political beast of burden more important than the chariot of man it is meant to draw.” (Irish Impressions, 1919)

When the “end-game” is improvement of the human condition, no institution has been more durable than that of higher education in pursuing that object. From times of Socratic and Hippocratic schools to the more formalized educational center of al-Qarawiyyin in Fez (Morocco) in 859 and then Bologna’s “first” university in 1088, and present-day colleges and universities, higher education has aspired to create the citizens, ideas, occupations, and technologies of the future. In a Darwinian sense this is why they endure and grow, yet even complex multiversities, such as UM, remain imperfect in extending their opportunities fully.

We educate medical students and residents to become tomorrow’s urologists, anticipating they will be the leaders and best of urologists. The founder of UM Urology, Hugh Cabot had an even larger view as Medical School Dean, explaining this in 1925 at the 36th annual meeting of the Association of American Medical Colleges in Charleston at the Fort Sumter Hotel October 26-28. His talk “Should medical education be importantly recast?” concluded with this paragraph.
“Finally, but perhaps most important, throughout the whole period of education the goal must be kept in sight, that goal being not the successful practice of medicine but the successful service to the community. If at any point either teacher or student loses sight of service as the paramount object of the practice of medicine, then medicine will fall from its high estate and be classified, and deserve to be classified, as a trade rather than a profession.”

Those remarks anticipated comments made 35 years later on the steps of the Michigan Union by another Bostonian, Senator John F. Kennedy, in a presidential campaign speech on October 14, 1960.
“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.”

Hope is tempered by the blues throughout this global village in October 2020, besieged by pathogens, tribalism, extremism of all sorts, authoritarianism, economic challenges, kleptocracy, and environmental deterioration.

 

Yet, October is still a time for optimism with belief in human ingenuity to fairly share the harvest bounty and solve the problems of our times. When the talent pool for human invention is maximized by including all people, the likelihood of good solutions is increased. The short burst of autumn colors, soon ahead, is one of nature’s best antidotes to the blues before we put on winter clothes, accommodate to the gray skies of Michigan winters, and pull up comforters and quilts at night. [Above: Autumn streets, Ann Arbor 2020. Below: Halloween by Grandma Moses, 1956.]

 


Thanks for reading Matula Thoughts, October, 2020

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

 

 

 

 

     

    Ga-ga now and then

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    DAB Matula Thoughts June 7, 2019

    Ga-ga then and now

    2172 words

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

     

    One.             

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

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

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

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

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

     

    Two.

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

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

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

     

    Three.

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

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

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

     

    Four.

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

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

     

    Five.

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

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

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

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

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

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

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

     

    Ga-ga notes

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

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

     

    David A. Bloom

    University of Michigan, Department of Urology, Ann Arbor