Matula Thoughts July 3, 2015

 

Matula Thoughts July 3, 2015

Independence, PGY1s, peonies, & art.

3673 words

 

©Photo. R.M.N. / R.-G. OjŽda

©Photo. R.M.N. / R.-G. OjŽda

Wash Monument

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

Magna Carta

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

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

declaration-of-independence

[1337 well-crafted words]

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

 

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

 

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

AME Church

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

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

 

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

PGY1s 2014 copy

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

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

 

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

 

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

Sick Kids fellows

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

Sick Kids

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

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

Tim O'Brien

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

 

 

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

 

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

Mepkin

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

Peonies Yun_Shouping Freer

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

Peony gardens

[UM Peony Garden, June 7, 2015]

 

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

 

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

Chang 2013

 

Chang 2014

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

 

Tom & Sharon 2013 copy

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

 

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

Triple prof

[Julian Wan, Khaled Hafez, Ganesh Palapattu]

 

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

David A. Bloom

 

 

Matula Thoughts January 2, 2015

Matula Thoughts January 2, 2015

Michigan Urology Family

Watersheds, leadership, & 2015 again

3676 words

 120px-Glycine-zwitterion-2D-skeletal

 

1.     Happy New Year. Its hard to believe 2015 is already here, but this fact reminds us once again that the forward march of time is relentless and time runs backward only in our imagination. History, nevertheless, still defines us with each new minute, new day, and new year serving as a watershed framing the past and future. This new year of 2015 is a significant watershed for everyone who will reach a milestone age in it, whether 40, 50, 60, 70, or even more years having enjoyed the contingencies of genetics, circumstance, modern health care, physical safety, and luck. As I begin the year at a significant personal watershed Gary Faerber is already in place as Acting Chair, following the previous turns of John Wei and Stu Wolf, who then returned to their roles as Associate Chairs with quantum leaps in knowledge, talent and leadership for the department. When Dean Jim Woolliscroft and I set up this experiment in leadership succession a few years back, I had no doubt it would be successful, but hardly imagined the great degree of success. Leadership is something everyone provides at one level or another in our organization, as well as within their families and communities. Leadership is a focus for us in our department, and certainly no less in the rest of the university from our valiant football team among the other athletic programs, throughout the 19 schools and colleges, in the Musical Society and a myriad other parts of the UM as it approaches its bicentennial. No one, even among the overpraised CEOs who write best-selling memoirs, is a perfect leader at every challenge in their life and career. Published perspectives, naturally tend to be self-congratulatory vignettes of successes, usually with sparse mention of the shoulders of giants on whom such leaders have stood. Plenty of more general leadership books are available, a few of them worthwhile, and you can always discover more about the topic if you are intent on developing your skills. The best way to learn, I believe, is to take the initiative yourself and try to lead wisely, be self-critical and learn from your mistakes, as well as to learn from the examples (successes and failures) of other leaders. We have some fine role models among us in the Medical School and Health System as well as within our professional peers elsewhere. Flawed examples of leadership (sometimes found in our own mistakes) offer equally valuable lessons. On the national and international political scenes noteworthy leadership seems  sparser. Looking back to the 20th century only rare great examples come to mind.

 

 

2.     WSC 1874-1965. It was 50 years ago that Winston Churchill died having reached 99 years of age in spite of innumerable bullets, cigars, prodigious quantities of food and drink, to say nothing of his determined political adversaries. His death in 1965 was a significant watershed – few people have so completely and uniquely altered the course of human events as did Churchill,  on a number of fronts including 2 World Wars. Admittedly a Churchillphile, I nonetheless recognize his many imperfections, yet he was the perfect man to rescue the course of history from catastrophe. You can expect a number of new books published about him this year and one of the first of these is by Boris Johnson, the mayor of London. Many biographies and studies of Churchill have been written (and at least a dozen fill my shelves), but Johnson’s The Churchill Factor occupies a unique niche offering a timely analysis of Churchill’s  impact on civilization. The world would be very different today had it not been for Winston Churchill. Someone other than Gutenberg would have figured out the printing press, and the same goes for the contributions of Columbus, Watt, Darwin, Lister (eventually!), Ford, Gates, and most other innovators. Only a rare few individuals have turned the tide of world events so positively and against such great odds. Without Churchill the second half of the 20th century and probably these past 15 years into the 21st would have been very dark times. Amazingly he was around 70 years of age when his greatest tests presented themselves. It is inconceivable that World War II would have turned out as it did without Churchill.      

 winston_churchill 

[Churchill  at 10 Downing St. 1940, by Cecil Beaton]

 

 

3.     Impact. None of us is likely to have impact of Churchillian proportions, but that’s not to say that as individuals we are not serious about making a difference. At any watershed moment each of us is likely to question “the meaning of life.” I recently listened to the audiobook autobiography of the controversial evolutionary biologist Richard Dawkins wherein he said something to the effect that “Intelligent life only comes of age when it works out the reasons for its own existence.”  [Had I read the actual book I could be more precise and reference a specific page; whether you agree or disagree with his theological viewpoint, his evolutionary biology contributions have been significant.] All life forms struggle for their survival searching for a difference, whether a favorable environmental differential, a nutritional differential, or a reproductive differential. We humans share this biologic imperative of curiosity to discover favorable niches, but our drive goes further into the superorganism of our civilizations in that we want to “make a difference” in the social sense. For many people this drive is satisfied by a sense of being taken seriously, wanting our opinions to matter to others. For other people this drive is expressed in intense ambition to invent, create, build, or help others. The individual need to make a difference is part of the rich fabric of sociobiology, allowing brilliant flashes of greatness such as Churchill in his day and Pope Francis now in our time. The Pope’s extraordinary Christmas message last week to the cardinals and bishops who make up the Roman Curia, could apply equally well to any large organization. Francis warned against endemic “spiritual diseases” of bureaucracy including the pathology of power, the temptation of narcissism, cowardly gossip, and the building of personal empires. His courageous and unprecedented speech hinted at the darker side of sociobiology, namely the innate tendency of any social group (political, religious, ethnic, or national) to be manipulated by a single autocratic leader or inner circle of leaders toward ends inimical to the larger shared values of not just the particular social group but to humanity at large. Pope Francis is one of the rare leaders with the credibility and force of character to bridge disparate factionalisms within his organization or in the larger geopolitical world by appealing to a human commonality. With all the problems in the world, you might think we are overdue for a few more extraordinary leaders like Churchill and Francis.

pope-francis-ap2_custom-35b090fdb44d1cd3207660a63e5d93856a112c0a-s600-c85

[Front left to right: Israel’s President Shimon Peres, Eucumenical Patriarch Bartholomew I, Pope Francis, Palestinian President Mahmoud Abbas – June, 2014 during peace prayers at Vatican gardens]  

 

 

4.     Sociobiology and mission. The idea of sociobiology, initially postulated and named by E. O. Wilson, recognized that a very few species – humans among them – have achieved a superorganism structure wherein individuals spend their lives to support the objectives of larger social structures of teams and societies. He called these eusocial species. Humanity alone, however, has been able to articulate social objectives, create principles and working rules for their deployment, and produce functional models of government. Our work in the Department of Urology of the Medical School within the University of Michigan, while minute in the grand scheme of things, fits in perfectly within the sociobiology framework. Like any individual, any team, or any large eusocial unit we are subject to the same evolutionary pressures of maintaining relevancy and preparing for the changing environments of tomorrow. We spend significant time in our Department of Urology considering and reconsidering our mission. While I dont believe a leader should tell any organization its mission, I do believe that a leader should help the organization articulate its mission as well as keeping it lively in the work, plans, and lives of its stakeholders. Our mission of Michigan Urology is centered on health care: teaching it, doing it, and making it better. It boils down to this essential deliverable: KIND AND EXCELLENT PATIENT-CENTERED CARE THOROUGHLY INTEGRATED WITH INNOVATION AND EDUCATION AT ALL LEVELS. We mean it and we believe in it. Our mission here goes deeper than those specific words. We are a great public university with a medical school influential in the story of modern medicine. Our urology unit has provided many of the best ideas, techniques, and leaders of our field for the past century. I can point to strong evidence of our successes in the weekly Whats New electronic communication that John Wei coordinates for our department that you can find on our website. When you really consider our mission, you might recognize that our mission is to provide for tomorrow the tomorrow of our patients, our students, our residents, our department, our faculty and staff, our community, our field, our children, and our species. We thus fit very neatly in the milieu of a university – universities exist to make tomorrow better. No organization in human civilization aside from universities has carried out this specific responsibility of preparing for tomorrow, year after year, decade after decade, and century after century.  In the daily struggles of finances, politics, governance, and crises most universities plod ahead it is their nature to be conservative – doing their work well enough although below their potential to build that better tomorrow.

 

 

5.     The future. Imagining the future is also a task of art and fiction. The Time Machine of H.G. Wells, the stories of Jules Verne, Orson Welles’s War of the Worlds, and for our present generation the Back to the Future film trilogy are stories that resonated with me on the back end of my present watershed. The first of the trilogy was set in 1985 and it imagined a future set in 2015. In that future the gimmick that made time travel possible was a plutonium-fueled flux capacitor (which needed a jolt of lightning to start it when Marty went “back to the past” in 1955 and he couldn’t find plutonium). Going forward to the future, however, the flux capacitor’s energy required only household waste in a commonplace “Mr. Fusion Home Energy Reactor” in 2015.  We aren’t at that point yet in terms of energy production, but since we can imagine a Mr. Fusion Reactor, it seems likely someone or some team will eventually solve this existential problem. Back to the Future excited the public imagination to the extent that it was the largest grossing film of 1985. I loved it, my kids loved it, and my grandkids love it. What are the counterparts of the Mr. Fusion Reactor for urology, or for health care in general? Perhaps the best insights for this will come from people writing imaginative short stories.

 

 

6.      Predictions. Yogi Berra allegedly said: “Its tough to make predictions, especially about tomorrow.” Each New Year is full of promise and challenges, some expected and others unexpected. If we could spot the specific key threats and opportunities right now at the start of the year and plan around them we could take those plans to the bank, as they say. While we don’t have the gift of foresight or the mythical “Gray’s Sports Almanac” that was central to Back to the Future Part II, we still could make some good guesses. If, for example, we knew a large asteroid was headed our way (another theme explored in the cinema) we might take steps to ameliorate it. Or if we knew an Ebola-like disease were likely to become epidemic we might create a vaccine and public health measures to manage it. (Remarkably we’ve known about Ebola since 1976, but somehow were unprepared for it last year.) It’s not always as tough as Yogi thought. Even without Grays Almanac we can make serious bets and useful decisions. We actually have figured out some forms of time travel of which astronomical sciences and space probes are outstanding examples. You might consider literary science fiction a form of hypothetical time travel to the future.

 Sports Almanac

[The pivotal sports almanac, stolen by Biff in 2015 and taken back to November 12, 1955 when he made some lucrative bets.]

 

7.     Challenges 2015. What will be the immediate challenges for Michigan’s Department of Urology in 2015? At the top of my list is the matter of struggling to stay afloat economically in a punishing economic milieu. We have around 30 clinical faculty doing the actual clinical work that 16-17 full-time clinicians could perform, and doing that work at the top of the game. Why is this? The answer is that, as faculty members in a university, our non clinical moments are spent in educating the next generation, expanding the conceptual basis of urology through investigation, supplying a large amount of administrative expertise and effort to run our heath system, and leading regional, national, and international organizations relevant to urology. The fiscal problem is that even at best these other tasks that are so essential to our missions have zero to only fractional revenue streams to support them. Clinical dollars have made the academic missions possible, but those dollars are shrinking under ruthless pressure. Our aggregate faculty carries a phenomenal portfolio. As the person tasked with paying the bills I am challenged in recruitment and retention by more generous compensation schemes at most of my peer institutions. Like most of my fellow chairs, I face inimical wealth redistribution from the heath system to our greater university, the inefficiencies of our own hospital (as a patient here myself while I had great care from individuals and teams, I also experienced a number of disconnects that Ritz-Carlton might consider rookie errors in the hospitality business), and severe facility constraints  based on 20 years of inadequate strategic planning and execution. Maybe with a new university president and EVPMA in addition to a restructuring of our health system governance and management we might finally get things right. Do the new leaders recognize that the key to success for a great academic health care enterprise is (first and foremost) great clinical care? On the forward side of this immediate watershed the winners in health care (the best of class survivors in the Darwinian sense) will be the few places that offer unsurpassed state-of-the art clinical care with the best outcomes, safety, patient experience, employee experiences, lean processes, educational outcomes, research productivity, and successful fiscal spreadsheets. If the new leaders are not evangelically wed to this belief and fail to elicit the wisdom of crowds and the opportunities of lean processes, success will slip further and further away. The single large success I believe we can claim over the past decade here at Michigan has been the Faculty Group Practice, led by David Spahlinger. We are now poised to re-structure and expand it into the University of Michigan Medical Group. Will this new format embolden us to find opportunities to reinvent and optimize healthcare in 2015 or will we continue to struggle to stay in the game? I for one favor the former scenario – after all we call ourselves leaders and best? I believe 2015 is now or never for us.

 

8.     A watershed molecule. Eleven years ago on this day (the leap year 2004) the spacecraft, Stardust a 300 kg robotic space probe launched by NASA in 1999, successfully flew past Comet Wild 2, collecting cosmic dust samples from the coma of the comet. Wild-2 is as old as the Earth and was discovered in 1978 by Swiss astronomer Paul Wild. For most of its time the comet orbited the Sun in the far reaches of the Solar System until 1974 when its orbit was changed by the gravitational pull of Jupiter bringing it just inside the orbit of Mars on its closest approach to the Sun. Its orbital period has thus gone from from 43 years to six years. Wild-2 has a 5 km diameter that wouldn’t do us much good if it came much closer to Earth’s celestial path. Stardust fulfilled its mission and returned to Earth in January 15, 2006 with its samples. Initial findings of the analysis were published in papers in Science in December, 2006. Analysis of the comet’s dust by a mass spectrometer on board revealed, among other things, glycine – an amino acid of great importance. Among the 23 proteinogenic amino acids, glycine is not only the smallest, but an organic chemist might consider that it is the smallest one structurally possible (it has a molecular weight of only 75 and its codons are GGT, GGC, GGA, and GGG). This is also the only non-chiral amino acid. Most proteins have only small amounts of glycine, although collagen consists of about 35% glycine.

120px-Glycine-zwitterion-2D-skeletal

A science fiction writer might conjecture that this was a watershed molecule between simple cosmic elemental combinations and the complex organic structures that comprise the building blocks of life. What glycine was doing in interstellar space boggles the imagination, but it fuels the belief of many that building blocks of life came to Earth. Water was also discovered among the comet’s bits of dust, although that was expected. To analyze the interstellar dust further, one million photographs will ultimately image the entirety of the sampled grains. The images will be distributed to home computer users so they can aid in the study of the data using a program titled, Stardust@home.

[Wikepedia: Top left – fuzzy blur of Wild-2 in space, top right – 

the comet close up , Bottom- Stardust] 

250px-Comet_81P_Wild_2010-01-17  120px-Wild2_3 

290px-Stardust20110323-full

 

 

9.     What’s New – reprise. Early in Y2K when I was working in Allen Lichter’s Dean’s Office, we began a monthly email to all the medical school faculty that we called What’s New. The belief was that some occasional, constrained, predictable, and enumerated communication to the entire faculty might be useful, interesting to some, and preferable to a constant stream of regurgitated and often random messages of deemed importance. When I became chair of urology we produced a weekly What’s New for faculty and residents, with only very rare other communications. This went out every Friday. In time I began to distribute the first of these editions on the first Friday of each month to our entire staff, Nesbit alumni, and friends of the department. As the email chain got a little tricky to manage I learned to set the first Friday What’s New up as a blog that we call Matula Thoughts. It has been a learning process and it still is a work in process. John Wei, as Associate Chair for Communications, manages the 3-4 other What’s New columns every month and usually has someone or some unit within our department “guest edit” each of these. He has innovatively added a little query to each issue to test the waters of opinions within our department.  If you ever want to roll back the pages of time for Michigan Urology since 2007, you can find old editions kindly archived by Rick Saur.

 

 

10.    Screen shot 2014-12-28 at 10.10.09 AMMatula Thoughts – going forward. You may fairly view What’s New and Matula Thoughts as displays of vanity. On the other hand, don’t we all want to believe that our thoughts matter to others, and in setting them down and presenting them in the public marketplace of opinions we shape them, we refine them, and we test their value (and by their proxy, our own individual value). For me to some extent, these columns have become forums to comment on phenomena, questions, papers, books, or events that I think are worth your consideration. Equal rights to thought-sharing is a fundamental basis of any democratic society, or indeed the basis of any highly-performing team. We set up these little forums of What’s New and Matula Thoughts not just as our departmental soap-boxes, but as a venue for others such as you in which to participate. What’s New is sent out by email to around 550 people, whereas Matula Thoughts, the blog version that we have been struggling to master, is picked up by a much smaller but more diverse band of readers. Even though the blog version has only a small readership at this point in time, we can track it and have found a surprisingly wide international reach as the screen shot above shows. [I took this December 28 from the WordPress statistics page for Matula Thoughts] The Canadian readership may be huge in terms of geography, but I doubt we actually have many Inuit readers. We invite (indeed, we often cajole or nudge) others onto these electronic soap boxes each week.  It is has been said that some professions attract people with extreme forms of narcissism, politics and professional sports being notable examples. Surgeons probably belong closer to one end of the spectrum than the middle. Yet we humans are all necessarily narcissistic to some extent, and the need for the interest of others, if not their admiration, is perhaps a surrogate for our very basic desire for personal relevance and meaning. Of course extreme narcissism, in its sense as a personality disorder (an interesting term in itself, for what is it, after all, that constitutes an ordered personality?) is the overwhelming need for admiration paired with a severe lack of empathy toward others – the antithesis of a good clinician. As physicians and surgeons, as faculty and staff, as nurses or PAs or MAs, as colleagues and friends we all reverberate to the belief that our thoughts matter and therefore, of necessity, the thoughts of others must be heard and considered with the same relish that we offer our own. So with that last thought at this watershed moment, Happy New Year, and good luck to us all now that we are back to the future in 2015.

 

 

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

David A. Bloom

Department of Urology

University of Michigan Medical School.

 

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