DAB Matula Thoughts April 7, 2017
April facts – mischievous & urological
April, the first 30-day month of the year, opens up the northern hemisphere spring with welcome visibility of diverse flora and fauna. It should surprise no one that the diversity of life sustains all life on the planet and loss of that diversity imperils everything. A multitude of critters share our space and today it is the wombat that comes to my mind. Australian newspapers The Sydney Herald and The Age reported a wombat attack this day in 2010 when a man named Bruce Kringle ended up in the hospital after mauling by the marsupial. The worldwide British Broadcasting Corporation quickly picked up the news. These sizable animals average over 3 feet and 60 pounds as adults. [Photo by JJ Johnson. 29 November 2009. Taken at Maria Island National Park, Tasmania.] Territorial infringement was likely in play in this instance, as the victim was living in a camper when he stepped out the door and encountered the angry wombat, unusual behavior for the animal and ultimately self-destructive after Kringle found an ax and made short work of it on this summertime February day in Australia.
The Wombat coincidence this day on this April day piqued my interest, because in a previous April, 1998, the British Journal of Urology (BJU) published an article on wombat uroflowmetry. [D. Johnson. Case report. Observations on the uninhibited bladder of the common wombat. BJUI. 81:641-642, 1998.] For those readers uninitiated regarding matters of scientific micturition, uroflowmetry is the measurement of the flow rate of urine during the process of emptying the bladder. Mankind is naturally curious about its personal byproducts and inspection of sputum, urine, feces, etc. has offered clues to understanding disease since the times of the earliest healers. Of course most mammals have olfactory interest in their own urine and that of others, as evidenced in the canine world. Uroflowmetry provides true facts about urination, thanks to our ability to measure time and volume, as well as understand velocity.
My interest in uroflowmetry preceded the wombat stories and goes back to Walter Reed Army Medical Center where my chief, Ray Stutzman, introduced me to the concept of timed uroflowmetry and we wrote a paper comparing it to instrumental uroflowmetry. [J. Urol. 133:421, 1985] I then wondered about uroflowmetry in other species and the elephant seemed a good place to start. Discussion with the elephant-keeper at the Washington National Zoo taught me something about pachyderm urologic habits, but we never completed the project, mainly because of a difference of opinion on the distribution of the tasks required by the methodology. Timed uroflowmetry requires a collection device and a stopwatch to measure the volume during 5 seconds of mid-flow. All of the elephants at the Washington Zoo at the time were female and their streams therefore required a collection device both large in volume and wide in aperture– basically a big bucket. The unpredictability of elephant micturition required someone standing in place with the bucket. Since the uroflowmetry idea was mine and the elephant-keeper was on better terms with the pachyderm than I was, it seemed reasonable for me to hold the watch while the other guy held the bucket. The elephant-keeper disagreed with that assignment and claimed the stopwatch. Given that stalemate, the study has yet to be performed and awaits an ambitious medical student or resident, or a more flexible elephant trainer.
Another elephant crossed my path around this time of year after Ed McGuire brought me to Michigan. A child with gross hematuria presented to clinic with her grandparents and we diagnosed urologic malignancy. After surgery she remained in hospital for further treatment and by this point the parents had come to town. They were circus people and owned a number of animals including a young female elephant. Domino’s Farms graciously allowed the family to camp out on their property for the weeks of therapy, and one spring afternoon the child’s family invited our pediatric urology team and kids for elephant rides.
Planarial detour. Scientists crave facts and know their job is to ferret out true facts. Bill McRoberts, colleague in Kentucky, friend, and our third Duckett Lecturer at Michigan used to tell his residents “a little fact trumps a lot of myth,” an idea parallel to Coffey’s advice to trainees: “you have to understand the difference between facts and true facts.” Evidence, analysis, and experiment are the ways we come to verifiable truths and enduring realities that constitute true facts. While all biological creatures deal with facts of their environment, many facts are only transient realities. A planarium, for example, may sense that its world is 20°C and that food is available straight ahead of its momentary motion, but those facts may change quickly. We humans can examine myths, discover momentary facts, create hypotheses, and perform experiments in search of something we call the truth, an aspiration we think is unique to our species.
Planaria, by the way, are among the simplest animals to manage their waste with a dedicated excretory system. Paired flame and tube cells ending in a pore assemble as protonephridial tubules along the length of the flatworm. These are capable of regeneration. [JC Rink, HT-K Vu, AS Alvarado. The maintenance and regeneration of the planarian excretory system are regulated by EGFR signaling. Development. 138:3769, 2011] Planarial flow rates could be a topic for a future study. More practically, the mechanism of planarian excretory regeneration could be turned to human renal replacement therapy, thus proving the point that today’s obscure fact may be tomorrow’s revolutionary insight.
[Above: planarian Dugesia subtentaculata. From Santa Fe, Montseny, Catalonia. Wikimedia Commons. Eduard Solà.]
[Above and below: reproductive and excretory systems of flatworm. Source – Wikimedia Commons, Putaringonit.]
When the wombat uroflowmetry paper in the BJU caught my attention in 1998, I suspected a prank, something not unknown in British medical publications, particularly around the month of April. Thinking a clever reply might be appreciated by the journal, I resorted to limerick form in a letter to the editor, Jeff Chisholm. Surprisingly, my letter was published and now constitutes the only “poetry” of any sort to find its way into my CV. [DA Bloom. Re: Wombat uroflowmetry. BJU 83:365, 1999.] Chisholm annotated my reply: “Edited versions – apologies to the author!” The annotation was in this limerick:
“Lo, the wombat – it all must be true
So free when it’s not in the zoo
Pees lots when it poops
By well-used neural loops
As told in the new BJU”
Pranks, myths, and propaganda veer from the true facts attended to so carefully in our professions. Last spring, sitting in on the class my daughter Emily, assistant professor in English, was teaching at Columbia University I heard her challenge a familiar myth with data from a paper in Science. [Mehl. Science. 317 (5834): 82, 2007.] The myth was that women spoke more than men, and observation of my children and grandchildren still supports that idea. The thing about myths, however, is that they usually short-circuit our best efforts to think critically. Appealing to the lazy tendencies of our brains, they get an easy pass for “truth.” Although I subscribe to Science, I had missed that particular article (and likely hundreds of other important ones since then). Matthias Mehl, associate professor of psychology and author of the paper, studied 210 women and 186 men with a voice-activated device that captured 30 seconds of conversation every 12.5 minutes (5% of the day) and found that women used 16,215 words and men 15,669 words daily – no significant difference. One might argue that possibly women used longer words for more complex conversations, and inspire another study. Another question, also heavily dependent on educational, socio-economic, and occupational levels of subjects tested would be how many words does “an average person” hear every day? It is likely that fewer words are actually comprehended than spoken.
Word count interests me in relation to this monthly column, What’s New/Matula Thoughts. Approaching 4000 words it offers a substantial amount to read, a quarter of what most people speak every day. It is surely vain on my part to think that the general readership consumes all these words critically, although a few friends read this more carefully than I write it. My point in writing, however, is that it fills some fundamental personal need to communicate beyond the simple necessities of survival and daily work, the need that our distant ancestors (Homo sapiens, Neanderthals, and their hybrids) fulfilled some 30,000 years ago on the walls of their cave dwellings. These particular electronic postings you now read are hardly so novel, artistic, or durable.
More on words. Considering a career in urology a medical student at Pritzker Medical School in Chicago, Logan Galansky, recently contacted me for advice and as she explained her previous work in hearing and learning she described the 30 million words idea – the hypothesis that children who heard that many words by age 3 years had a lifetime advantage over those who were exposed to much less. [B Hart & T Risley. (2003). The early catastrophe: The 30 million word gap by age 3. American Educator, 27(1): 4 – 9.] Complicating any easy assumptions, however, is the fact that the study compared children from “professional families” to children from “impoverished families” in Kansas City, KS in the 1960’s where other confounders beyond experiential words were at play. The pivotal study involved 42 families that were divided into 4 socioeconomic groups. Although scrutiny detracts from the easy conclusion it certainly is plausible, if not likely, that richer vocabulary experiences build more robust vocabulary inventories, and those inventories are an advantage in life.
Our Department of Urology Faculty Retreat next week is a sort of spring training for the next decade of urology at the University of Michigan. Each clinical division and key domain, such as education or the Dow Health Research Division, will present strategic visions. Individual faculty have updated their web profiles and we should get a pretty good sense of ourselves as an organization today and what we hope for in the intermediate future. How many words will be spoken at this retreat? Given pauses, breaks, and other interruptions, and assuming a leisurely rate of 100 words per minute (130-150 wpm may be more typical of conversational speech) over 5 hours we may hear 30,000 words. Who knows what will stick or what people will take away, but I hope we will align around our mission and that we will understand our divisional strategies and visions of the future.
Disparities. Important lessons from Star Wars, observed by The Economist and mentioned here last month, bear repetition. First, economic disparities are inevitable in the galaxy, in spite of advancing technology. Second, although free trade advances economic growth, free trade will never benefit everyone equally; some “humans will still labor at dangerous and unpleasant tasks” because of inequities within political systems.
Society benefits substantially by mitigating disparities that, while inevitable in humanity, impede the common good. Society gains when its entire human capital is educated, productive, healthy, and kind. If only certain privileged subsets of its potential workforce have opportunity for education, employment, and productivity, then the potential of that society is diminished. A generation ago, scientific investigation of healthcare disparities was not high on the ladder of interest in academia, federal funding, or industry. This has changed greatly, and our Urology Department Dow Health Services Research Division reflects the new attention. An important paper in JAMA earlier this year looked at trends and patterns of disparities in cancer mortality by counties in the USA from 1980-2014 and the results relevant to urology are riveting. [AH Mokdad et al, corresponding author CJL Murray JAMA. 317:388-406; 2017.]
The United States is a large and diverse country, but why people with specific diseases should have different regional disease frequencies, expectations of care, and survival is a complex question with many answers. Regional variations of disease frequency and survival can depend upon environmental factors such as air or water safety, occupational hazards, poverty, food safety, public safety, weather conditions, and many other factors that vary according to geography and socio-economic conditions. Looking at the maps we have to agree with Dorothy, in The Wizard of Oz, that the center of the country is a good place to call home.
Centrism. A cornerstone aspiration of American representational democracy is justice, opportunity, and dignity for all participants. This must be balanced against the centrist tendency inherent in majority rule of the electorate. Cosmopolitanism must be respected and those who are disadvantaged require a humane safety net. Life, liberty, and the pursuit of happiness are those basic Jeffersonian beliefs articulated in the Declaration of Independence, but even after more than 200 years they remain work-in-progress, complicated by a world that is rapidly changing in terms of socio-economic, geo-political, environmental, demographic, and technology factors.
The political center of the United States will always be a matter of debate, however the geographic center of the contiguous United States according to the US National Geodetic Survey is 39°50′N 98°35′W. This spot happens to be in Kansas, approximately 12 miles south of the mid Kansas–Nebraska border and 2.6 miles northwest of the center of the city of Lebanon. Not too far south and east of that point is Abilene, Kansas where Dwight David Eisenhower was raised.
Health care is unquestionably wrapped up in the idea of life, liberty, and the pursuit of happiness, and healthcare politics concerned most presidents even before the mid-20th century. Around that point in time the AMA position was that the federal government should not be involved in healthcare, while Truman favored national health insurance and Eisenhower sought legislation to support the healthcare insurance industry.
On April 16, 1953, twelve weeks into his presidency Eisenhower delivered one of his greatest speeches. This was just a month and a half after the death of Stalin and, as the president then knew, the first hydrogen bomb would be tested within a year (code-named Castle Bravo it was detonated March 1, 1954 at Bikini Atoll, Marshall Islands). Eisenhower saw an opportunity to reset the increasingly costly escalation of the cold war. The occasion was a meeting of the American Society of Newspaper Editors in Washington, DC. Eisenhower worried about the disparity between military spending and the spending of a nation on the life, liberty, and pursuit of happiness of its people.
“In this spring of 1953 the free world weighs one question above all others: the chances for a just peace for all peoples… “
No one dared remind Eisenhower that liberty required a robust and costly position of defense, but he was convinced that the escalating costs were not only excessive, but also realistically unnecessary. He believed that the nations of the world had reached a point where the worst that could be expected by the escalation was terminal nuclear war while the best hope was
“… a life of perpetual fear and tension; a burden of arms draining the wealth and labor of all peoples; a wasting of strength that defies the American system or the Soviet system or any system to achieve true abundance and happiness for all the peoples of this earth. Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed those who are cold and not clothed. The world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children.”
He noted that the cost of one heavy bomber equated to modern brick schools in more than 30 cities, a single destroyer equalled a new home for 8,000 people, or a fighter plane cost a half million bushels of wheat. Inflation and technology have pushed the costs much higher.
The Nesbit Society and the AUA come to mind as spring approaches. The AUA originated in 1902 in New York City when urologist Ramon Guiteras felt the need to congregate with other urologists. Barely 17 years later his colleague Hugh Cabot in Boston, returning from WWI, began preparations to move to Ann Arbor attracted by the opportunity to organize a medical school and hospital system to suit the changing times of health care. Cabot’s successor, Reed Nesbit, became the first head of urology at Michigan, presiding for nearly 40 years, followed by Jack Lapides. The Nesbit Society was formed in 1972 under the leadership of the Nesbit/Lapides trainee John Konnak, who by then had become a faculty member. The legacy of these great teachers and urologists is the Nesbit Society, now with 324 members. To a large extent, it is the Nesbit Society to whom this monthly electronic posting is directed (although a few members prefer a hard copy and Sandra Heskett graciously obliges). It is always a delight for me to hear from our Nesbit alumni and friends. John Hall (Nesbit 1970), for example, sent me this phrase that has informed his practice throughout his excellent career in Traverse City: “We don’t practice medicine until we get it right, we keep on practicing until we will never get it wrong.” Hall’s Theory of Medical Education, like the Hippocratic aphorisms, distills wisdom into a phrase that you can carry around and re-inspire yourself when the going gets rough on a given day in clinic or operating room. This is one of the ways good professionals inoculate themselves against burn-out.
The Nesbit Society meets twice a year: once during the AUA national meeting in Boston this year on Sunday May 14 and all Nesbit members and friends of the department are welcome. The second occasion is our alumni weekend here in Ann Arbor September 14-16.
Most species congregate and the chairs of our academic departments do this with some regularity. I came across this picture of such a congregation 3 years ago in April when Mike Johns was interim EVPMA. This particular dinner was at The Earl, and the picture was taken before everyone had arrived, but it turned out to be my best picture of the evening. [From left: Karin Muraszko, Valerie Opipari, John Voorhees, Mike Johns, Carol Bradford, Reed Dunnick.]
The clinical departments are where the rubber meets the road in carrying out the missions of our UM Health System mission. Departments have been the building blocks of universities for hundreds of years, and academic medicine departments have effectively educated their successors, expanded the conceptual basis of their fields, and performed the essential transactions of clinical care over the past century. The clinical mission is the milieu for education and research as well as the financial engine for academic medicine. The changing economic, regulatory, and technological environments threaten the delicate balance of that mission. At Michigan our ambulatory care unit (ACU) model of delivering care has been successful, with the healthcare providers in central roles of making local operational general strategic decisions more effectively than management by managerial accounting methodology. This is largely the concept of lean process management. Clinical departments bring a third dimension of the academic mission to ambulatory clinics of providers and patients.
April, the cruelest month in the view of TS Eliot, can be mischievous and its first day, April Fool’s, sets the tone. The origin of April Fools Day, may well have to do with April being the first calendar month of the year in medieval European towns when March 25 marked New Year’s Day. April in Ann Arbor often brings mischief since a given day may be spring-like while the next might be wintry. That shouldn’t be surprising, as nature routinely throws curve balls to test our fitness. Actually, yesterday afternoon I saw snow flurries from my office window and more snow last blustery evening.
[Above: April 2, 2016 at home. Below: April 13, 2016 Old Mott on left, Main Hospital center, and Taubman on left.]
Biology’s astonishing diversity sustains our particular human biologic niche, yet ironically our very presence as a species chips away at biologic diversity and erodes our niche. This erosion has been going on for a long time and the angry wombat is only one tiny example. Its likely ancestor, the Diprotodon (meaning two forward teeth), was the largest known marsupial and a member of the Australian megafauna that existed from 1.6 million years ago until extinction around 46,000 years ago. That latter date coincides with the time our human ancestors were making their first cave dwelling paintings as they were eating the megafauna. Koalas and wombats are, perhaps, miniaturized surviving versions of the rhinoceros-sized Diprotodon. The wombat’s dental plan facilitates its Darwinian niche, allowing it to tunnel forward vigorously. Cleverly, its marsupial pouch opens retrograde, to avoid collecting dirt as it burrows. After 3-week gestations, the young live in the pouches for 6-7 months, but still do not wean until 15 months of age. Wombats have no tails and their tough rear hide is cartilaginous most posteriorly, making it resistant to predators. Wombat scat (below) is oddly a nearly perfect cubic form, somehow resulting from its peculiar physiology. Wombat groups are variously called wisdoms, mobs, or colonies. [Wikipedia facts, Photo JJ Harrison]
As the environment changes, you never quite know what to expect each day going forward. One value of knowing some history is that it gives you a little confidence of what to expect. For example, if you know the earthquake history of your location has a frequency of once in a millennium, with the last recorded 100 years ago, you might reasonably conclude that it is safe to live there. More immediately, if the sidewalk you are about to traverse is riddled with pigeon droppings, you might cross the street to walk on more auspicious pavement. When Bruce Kringle woke up 7 years ago in Australia, he certainly had no idea that an angry wombat was going to take him on when he stepped out of his mobile home, although had he examined the ground he might have recognized its unique cubic scat.
[Wikimedia Commons: Bjørn Christian Tørrissen. http://bjornfree.com/galleries.html.]
Postscript. John Barry, in response to the picture of the Olds 88 last month wrote: “Looks like a 1951 Oldsmobile 88 K-body 2 door sedan with a V-8 engine and a Hydramatic transmission. I had one when I was a senior in high school. Great car. I used to buy cars, fix them up and resell them from my parent’s driveway.
Thank you for reading Matula Thoughts this April, 2017.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor