December

Posted by dabloom

Matula Thoughts

December 4, 2020

Change and hope

2810 words

One.

Hope. Change and uncertainty are inevitable, but hope is the part of the human tool kit that helps people navigate life’s turbulence. Change may bring hope or horror, as imagined in the fictitious scenario (shown above) of audience response to the novelty of moving pictures in 1895 when the magic of film was an expectation beyond reasonable hope. [Above: “Panic in the Audience when Lumiere Shows his first Film.” Figure from Suddenly this Overview. Peter Fischli and Davis Weiss, Exhibit, Guggenheim Museum, April 2016.]

It is rational to hope that things will return to a semblance of normal after this “final wave” of Covid-19 disrupts workplaces and education, prolongs social isolation, and disturbs belief in science and reason. Humans rebound after bad times and new forms of creativity emerge from calamities, as seen with RNA vaccines. Still, we would do better to remember those bad times and plan for their inevitable return. [Below: Michigan Theater – mostly closed in Covid times and its big screen moving pictures sorely missed.]

Last year just around this time, our department hosted its annual Holiday Party, an event inaugurated by Jim Montie after the Urology Department emerged from a Department of Surgery division 20 years ago. As the department expanded, the get-togethers outgrew Ann Arbor venues and moved to Fox Hills Golf & Banquet Center with the help and generosity of Kathy and Mike Aznavorian. Further growth and blurred administrative boundaries over the years stretched even Fox Hills’s capacity for the UM Urology family, their children, and guests to mingle, see Santa, dine, and dance. A few of our staff put their hearts and souls into planning and deploying the event, with food, avionics for Santa, and gifts for children. When the financial uncertainty of 2008 struck, we hesitated but continued the party. Little did we anticipate an emergent virus from the other side of the planet would break our annual run of holiday parties. Covid not only brings the monetary concern, but also precludes the social interaction and reminds us how much we miss gathering.

[Above: Santa, Holiday Party 2013. Below: Keller and Osawa families, Holiday Party 2015.]

UM Urology has gotten so large and far-flung that hardly any of us knows everyone else – a far cry from my first days here in Ed McGuire’s Section of Urology. With clinical and research activities of our department in at least 15 geographic locations, the challenges of communication and cultural identity are great. Families, organizations, and nations tend to grow far from their roots, straining integrity of the whole. Periodic gatherings can be forms of thanksgivings to recall roots and purpose, restore connectivity, and celebrate diversity. We hope and expect to gather again.

Two.

Origins. With December here, a new year just around the corner, and the second century of urology at UM ahead, thoughts turn to the origin stories that ground our views of the world. Personal origin stories as well as organizational ones are idiosyncratic and complex – and all are rich in certainty, invention, and selective memories. The UM urology narrative, is assembling on our website. [Above: Cropsey painting of early UMMS.]

https://medicine.umich.edu/dept/urology/about-us/our-history/origin-story

Origins are never perfectly clear. The past can never be fully ascertained or known as completely as it actually happened. It can, however, be illuminated and investigated not merely out of curiosity but also to understand options for today, reinforce essential values, and prepare for the future. Our origin stories are lean in the details of the original peoples of the Americas who were displaced by explorers and colonists. Examination of origins forces us to see what’s missing, what’s right, and what’s wrong, thus giving opportunity to improve what’s lacking and what’s incorrect with ourselves and our organizations.

Historians elicit facts, create narratives of the past, and measure it all according to values then and now so as to understand the meanings of those stories. This expansive evaluation is, at first glance, contrary to that of scientists who generally take reductionist approaches that render observations to the simplest explanations. Through methodological analysis scientists may hope to find grander truths in general rules, laws, and theories. Health care providers, ideally, combine the story of a patient (the larger narrative of their past and present) with the facts of observation and clinical investigation.

Three.

Urology is a small detail in history’s medical narrative and its roots at the University of Michigan are uncertain. [Above: medieval uroscopy – man with a matula.] We have no practice logs from UM’s first genitourinary surgeons, Cyrenus Darling and Ira Loree, nor reminiscences to know what they thought of the 1902 “urology” neologism, although they chose not to adopt it. Their recollections of WWI and the Influenza Pandemic can be assumed unpleasant, but how those large events affected their daily lives, families and friends, and political responses can only be vaguely imagined. Who in their time would have thought that the “war-to-end-all-wars” would be followed so quickly by another one and who knew that the 1917 pandemic would end after a third wave in 1920? Who could have doubted that other pandemics wouldn’t follow? Most astonishingly who would dispute, today a century later, that face masks, social distancing, and rudimentary hygiene limit the spread of respiratory infections?

The thoughts of Darling and Loree concerning their replacement in 1919 by “Modern Urologist” Hugh Cabot were not positive and those impressions were exacerbated by his brusque manner, causing their swift departure to the welcoming St. Joseph Mercy Hospital a block away. From this disruptive transition, the UM Section of Urology was born.

No less disruptively ten years later Hugh Cabot, Medical School dean by then, was fired by the regents after losing confidence of the faculty. Reed Nesbit, Cabot’s second trainee, built the Section of Urology from 1930 through 1967, when he retired to Sacramento. Then, after an uncertain six months, Nesbit’s trainee Jack Lapides, was named successor and continued the clinical, educational, and research missions of the Section of Urology from 1968 to 1983. Like Nesbit, Lapides trained a great cohort of urologists of all types, including a great string of pediatric urologists: Norm Hodgson (Nesbit 1958), Tomohiko Koyanagi (N’70 – see Postscript), Ed Tank (N’71), Steve Koff (N’75), Evan Kass (N’76), and Barry Kogan (N’81). Still under the administrative management of the Surgery Department, UM Urology gained Ed McGuire (trained at Yale by Bernie Lytton) as Section Head. This transition, too, caused disruption, with the loss of Ananias Diokno to the Beaumont system.

The five-person Section of Urology under Ed McGuire (above) welcomed me and my family to Ann Arbor in the summer of 1984. The small section of five is now the large Department of Urology of 50 full-time faculty led by Ganesh Palapattu. Our academic space, initially on the fifth floor bridge between the old Mott and old Main University Hospital, moved to the second floor Taubman Building when it opened in 1986, and then the third floor of Taubman in Jim Montie’s early years as Urology Chief. That space underwent a well-needed facelift this autumn. Although this is the administrative hub of the department, our faculty have offices in the Cancer Center, North Ingalls Building (the old St. Joes Hospital), North Campus Research Complex (our Dow Division of Health Services Research in the old Pfizer Research campus), Muskegon’s West Shore Urology, and clinical and surgical activities at more than a dozen other sites.

[Above: Taubman Administrative Urology. Sept. 15, 2020. Below: September 30, 2020.]

The challenges of this Covid year are not over, as we yearn for a return to social proximity and in-person conferences. The postponement of the yearly Nesbit Alumni Meeting, along with other regular medical and scientific sessions was disappointing, but not unprecedented. The AUA, for example, also cancelled this year as well as in 1918, 1919, 1943, and 1945.

Academic routines are changing into new normals, such as our zoom visiting professor lecture in mid-November from Jim Hu at Cornell, shown below in one of his slides. Still, we miss our conference rooms.

Four.

Narratives. The writing process for the UM urology story has strengthened my admiration of others far better at that art. My career, not primarily one of writing, was directed to what Hippocrates narrowly considered “the art of lithotomy,” but grew into its surgical cousins of orchidopexy, hypospadias repair, pyeloplasty, bladder reconstruction, and other needs of modern urology. Turning facts into authentic narratives is a different occupation and certain writers stand out: John McPhee and E.O. Wilson for nonfiction, or Kazuo Ishiguro and David Mitchell for fictional story-telling. McPhee at age 89 continues to weave artful narratives of fact and people, while Wilson at 91 explains science with clarity and grace. Mitchell at 51 creates tapestries of fact and imagination, crossing fictional genres. Nobelist Ishiguro, at 65, writes novels that explore the uncertainty of memory and its deceptions. The authenticity of great fiction is a mirror to reality; as the Good Lord Bird miniseries proclaims: “All of this is true, most of it happened.”

Our parochial story, The First Century of Urology at UM, is an accounting of real people and events that built a small specialty in a great public university amidst the contexts of its times, providing and creating state-of-the-art clinical care (such as it was), generating new ideas, educating successors, and leading colleagues.

We were fairly certain of the sequence of Nesbit’s early trainees and associates in our Origin Story of Urology at UM, but new information kept popping up. For example, Susan Dorr Goold, daughter of our recently deceased colleague Dick Dorr (Nesbit 1968), gave me pictures from her dad’s office but the identity of one drew a blank. Skip Campbell and Mac Whitehouse identified the photo as Rigdon “Rod” Ratliff, (Transylvania College A.B. 1924, UMMS 1929) who practiced urology at St. Joe’s. In medical school Ratliff became interested in surgery and urology under Cabot and Coller, and was likely influenced by Huggins and Nesbit – trainees and later junior staff under Cabot. With his MD in hand, Ratliff went across the street for internship at St. Joe’s and fell under the influence of Ira D. Loree, the UM genitourinary surgeon displaced nearly a decade earlier by Cabot. The cataclysmic stock market crash a few months into internship undoubtedly shaped Ratliff’s career plans and he remained at St. Joe’s in practice with Loree, the early years serving as a de facto residency in urology.

By 1935 Ratliff was considered a legitimate urologist and Nesbit appointed him “Instructor in Urology” without salary. Loree died on August 11, 1936 and Ratliff took over his practice, revising his UM title in 1938 to “Part-time Instructor,” allowing more time for St. Joe’s practice. Ratliff maintained this title until 1946. Curiously, Ratliff didn’t join the AUA until 1946, his application endorsed by Nesbit and Robert Breakey, a Lansing urologist. Ratliff continued to teach students and interns, and one of them, Tom Newman (Nesbit alumnus 1974 – now retired in Tucson), recalls Ratliff teaching him the “Water sink window test.”

Ratliff (above) collected urine samples in clear specimen bottles (modern matulas) before cystoscopy, holding them up to the window by the sink in the cystoscopy suite and if clear to daylight he poured the urine into the sink and completed the cystoscopy. Only if turbid, would he send the specimen for urinalysis, culture, and sensitivity. At University Hospital, however, Newman discovered a very different approach; Lapides insisted on routinely spinning the urine and staining it with methylene blue before examination under the microscope and then dipstick urinalysis, with culture and sensitivity, if necessary. One approach was practical and cost effective, the other was richly academic. Newman fondly recalls Rigdon as a quiet gentleman. Clearly, Dick Dorr shared that admiration. Ratliff retired in December, 1973, according to the AUA files (found for us by Tupper Stevens) transitioning his AUA status from active member at $75 per year to senior member at $15. At home on 231 Corrie Road in Barton Hills, Ratliff died of a heart attack January 29, 1977. He was the last link between Hugh Cabot’s era and ours.

Five.

The uncertainty of history. This turbulent political season, a friend referred me to the recent book, American Dialogue, by American historian, Joseph Ellis, who explained a central irony in his field.

“There is an inconvenient truth that most historians acknowledge under their breath, admitting that objectivity, in the sense that mathematicians or physicists, use the term, is not a realistic goal for historians. The best they can strive for is some measure of detachment, which serves the useful purpose of stigmatizing the most flagrant forms of ideological prejudice (i.e. cherry-picking the evidence to claim that Thomas Jefferson was an ideological Christian or Andrew Jackson was a New Deal Democrat). But as you believe that the study of history is an ongoing conversation between past and present, detachment itself is delusional. In his Style in History (1974) Peter Gay put the point succinctly: ‘History is always unfinished in the sense that the future always uses the past in new ways.’ In fact, the past is not history, but a much vaster region of the dead, gone, unknowable or forgotten. History is what we choose to remember, and we have no alternative but to do our choosing now.” [Ellis, American Dialogue, 1918. p. 7.]

Certitude, whether moral, intellectual, or political, is a tricky matter as reflected in this column last month when we tried to make a case for an enlightened Certainty 2.0 that allows one to retain some degree of uncertainty to allow for “I’m not so sure” and keep asking questions. Perhaps H.L. Mencken overstated the matter when he claimed that moral certainty should occupy a low rung in the ladder of human intellect, but he had a fair point.

The moral certitude of John Brown, in song, epic poem, or current Showtime series, The Good Lord Bird, epitomizes the smugness of Certainty 1.0. Timothy McVeigh’s ideological certainty terrorized Oklahoma City in 1995, striking against the Federal government by bombing a federal building, killing 168 people and injuring more than 680 others. Similarly, Ted Kaczynski (UM Mathematics Ph.D. 1967), certain that industrial-technological society was subjugating mankind and destroying the planet, responded by sending bombs to university faculty and airlines in 1978, to “get back at the system.” He wreaked havoc on the lives of random people who represented modern society or happened to be in the way of the bomb. This campaign precipitated a long FBI investigation that ended with arrest in 1996 (see Wikipedia). Religious certitude (perhaps a form of ideological certainty) fueled the destruction of the World Trade Center on September 11, 2001.

Self-serving certitude, another broad form of certainty, is that of psychopaths who justify their actions by personal convenience, often framed by occupation or paycheck, as mentioned here last month, with attribution to H.L. Mencken, Lewis Sinclair, C.E. M. Joad, and others: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Closely related is political certitude, as in recent seasons has tested the flexibility of the American Experiment.

Immaculate Misconceptions, the title of a section of the Law chapter in Ellis’s book includes two extraordinary quotes relevant to certitude and to stimulate your uncertainty as a reader we defer their sources to the postscript.

Source A. “When a case comes to me, I don’t do whatever I feel like doing, I have a standard. That standard is what would the people at the time the Constitution was enacted have said.”

Source B. “Some men look at constitutions with sanctimonious reverence, and deem them, like the ark of the covenant, too sacred to be touched. … We might as well require a man to wear still the coat which fitted him when a boy, as civilized society to remain under the regimen of their barbarous ancestors.”

These ideas relate to the question of the role of originalism or textualism in law. Adjudication of today’s uncertainties according to the exact words of a set of historic bylaws might be considered a cop-out, relieving decision-makers of consideration of contemporary complexities and values. One expects that was not Scalia’s intent in his heart of hearts, but rather his starting point to consideration of legal questions. We surely hope our judges and wise leaders struggle intellectually with uncertainty to arrive at a Certainty 2.0 in their consequential decisions.

Postscript.

Sources. A. Antonin Scalia, speech at the University of Fribourg, March 8, 2008. B. Thomas Jefferson to Simon Kercheval, July 12, 1816. [J. Ellis, American Dialogue, The Founders and Us. Vintage Press, NY, 2018. p. 151.]

The Good Lord Bird, is a 2014 book by James McBride on John Brown and its Showtime dramatic series offers an ironic introductory quote, “All of this is true, most of it happened.” This complements Don Coffey’s enduring admonition to his research students to try to understand the difference between facts and true facts, reminding how certainty is tenuous but some things are deeply true to us.

Congratulations. The Japanese Government recently awarded Tomohiko Koyanagi The Order of the Sacred Treasure, Gold Rays with Neck Ribbon in recognition of outstanding contributions to medical education and research. https://en.wikipedia.org/wiki/Order_of_the_Sacred_Treasure

[Above: Tom Koyanagi. Below: Order of Sacred Treasure.]

Thanks for reading Matula Thoughts this December, 2020.

David A. Bloom, University of Michigan Department of Urology

Quilting bees and blues

Posted by dabloom

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

Sunrises, sunsets, & summer imaginations

Posted by dabloom

Matula Thoughts Aug 3, 2018

Sunrises, sunsets, summer imaginations & facts

3951 words

One.

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

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

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

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

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

Two.

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

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

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

Three.

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

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

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

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

Four.

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

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

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

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

Five.

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

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

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

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

Six.

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

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

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

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

Seven.

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

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

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

Eight.

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

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

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

[Above: Martha Bloom, George and Peggy.]

Nine.

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

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

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

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

Ten.

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

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

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

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

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

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

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

Birthdays, graduations, and centennials

Posted by dabloom

July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.

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

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

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

Two.

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

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

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

Three.

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

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

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

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

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

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

Four.

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

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

Five.

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

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

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

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

Six.

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

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

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

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

Seven.

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

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

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

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

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

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

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

Nine.

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

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

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

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

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

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

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

Ten.

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

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

Thanks for reading Matula Thoughts this July, 2018.

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

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

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

Spring and all

Posted by dabloom

DAB What’s New Apr 6, 2018

Spring and all

3476 words

One.

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

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

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

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

Two.

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

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

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

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

Three.

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

[Above & below: morels]

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

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

Four.

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

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

Five.

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

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

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

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

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

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

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

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

Six.

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

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

Seven.

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

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

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

Eight.

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

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

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

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

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

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

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

Nine.

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

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

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

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

Ten.

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

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

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

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

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

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

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

Why on the evidence of pictures is everything important?

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

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

Thanks for reading Matula Thoughts this April, 2018.

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

Matula Thoughts June 2, 2017.

Posted by dabloom

Qualification, adaptations, & stories

3876 words

One.

Ann Arbor’s redbud flowers are now gone in June, Memorial Day is behind us, and summer is at hand. Redbuds appeared in April and stole the foliage show until other flowers appeared and trees leafed out. I saw the last redbud flowers in early May and by mid-May they were gone (above & below: Mike Hommel’s tree – also shown in our May posting). Redbud flowers, more of a magenta pink than red, are pollinated by long-tongued bees. Other bees are not so well-qualified, as their tongues are too short to reach redbud nectaries, the secretory structures at the base of stamens containing the food that attracts pollinators. Generalist bees forage among all flowers, but specialist bees with tongues over 5.5 mm work the deep nectaries. Since the first “Adam and Eve” bees 100 million years ago, the creatures adapted to changing environments by creating diverse successors, some of which survived better than others in their temporal milieus. A Science paper showed Colorado bumblebee tongues shrank nearly 25% in the past 40 years, adapting to changing alpine floral diversity, but putting long-tube flowers like the redbud (and foxglove, Indian paintbrush, clover, snapdragon, and bluebell) at risk. [N. Miller-Struttmann et al. Science 349:1541, 2015] The mutuality or co-dependence of bees and flowers is one of nature’s fine arts. [Consultation from beekeeper-urologist Brian Stork of West Shore Urology in Muskegon.] Qualification in the sense of fitness for a purpose, skill, or accomplishment, is at the heart of evolution, civilization, and our specialized world of healthcare.

On the human scale, we adjust graduate medical education to produce a diverse set of our own professional successors, anticipating that they will fit tomorrow’s health care milieu better than my generation could if we cloned ourselves. In the next few weeks graduating residents and fellows across North America will become “qualified” to practice medicine after completing formal training in their specialties, although ultimately they will need board certification. The faculty backup they initially required, became redundant incrementally over their 5-8 years of training, so that by now they are more like colleagues of their teachers than trainees. Medical training, most keenly focused at the GME level, has done well in preparing the next generation of doctors for careers as qualified specialists. Urology residents and fellows in Ann Arbor are well-qualified with diverse clinical, research, teaching, and leadership talents to fit the diverse healthcare environments they will enter. Above all we hope their professionalism and critical thinking skills will be at the forefront of their lives and careers as they pollinate their fields and communities.

Once qualified, health care providers face the challenge of keeping up with the changing knowledge, skills, and technology of modern healthcare. One effective way to do this is through professional meetings and for urologists the American Urological Association, this year in Boston, is center stage. The MUSIC reception and the Nesbit Society gathering were worth the trip just by themselves. Sunday’s opening plenary session featured Julian Wan, as associate editor, giving a Journal of Urology highlights presentation, our alumnus Barry Kogan (current chair at Albany) moderating three debates, and Dana Ohl leading a transgender discussion. I could mention at least 100 other presentations, posters, panel appearances, and other “visibilities” from UM to say nothing of those of our alumni, but the national convention is far too big to get to most venues.

[Nesbit reception at Moakley Courthouse. Above: Gary Faerber University of Utah, Bahaa Malaeb, Lindsey Hampson UCSF, Noah Canvasser UC Davis. Below: Mahendra Bhandari – Vatikutti Institute, Khurshid Ghani, Meidee Goh, David Fry]

Two.

Education and medical practice were quite different 100 years ago as Russian physician-author Mikhail Bulgakov (1891-1940) relates in a story of a young doctor starting out during a cold autumn in rural Russia. The experience was likely similar in Europe, Africa, or the Americas until specialty medicine and formalized graduate medical education took hold. In a little more than 12 pages, Bulgakov tells a tale pulled from his experience in 1916 as a newly “qualified” doctor sent to a provincial town in revolutionary Russia. The young physician was terrified imagining his first medical crisis, for example, a patient might present to his clinic with an inguinal hernia, or even worse, a strangulated one. The doctor recalled observing only a single hernia repair as a student and even though surgical texts were at hand in his new office, he was well aware that he lacked any experiential knowledge: “‘I’m like Dmitry the Pretender – nothing but a sham,’ I thought stupidly and sat down at the table again.”

“The Embroidered Towel,” was one of 9 stories in Bulgakov’s collection A Country Doctor’s Notebook, written in the 1920s and translated into English by Michael Glenny in 1975. The story rings true to my experiences as a midlevel UCLA surgical resident rotating at San Bernardino Country Medical Center, pretty much on my own for general, orthopedic, and neurosurgical crises at night in the mid-1970’s. Bulgakov (above) began practice as a “qualified doctor” in a chaotic world buffeted by WWI and the Russian Civil War. His rural medical practice was cut short as successive governments drafted him as a physician, culminating with the Ukrainian People’s Army in February, 1919 sending him to the Northern Caucasus. After contracting typhus, he abandoned medicine for a writing career, as a journalist, playwright, satirist, and science fiction author. His early work was favored by Stalin, but later writing ran afoul of the Communist Party and one play, The Run, was personally banned by Stalin. Bulgakov’s satirical novel, The Master and Margarita, was published posthumously in 1966 by his widow. The author is said to have died of nephrosclerosis. The Master and Margarita has been the subject of films, mini-series, and a graphic novel rendering. A current book by physician Julie Lekstrom Himes, Mikhail and Margarita: A Novel, uses Bulgakov’s book as a platform for her own debut novel, set in 1933 Soviet Russia.

Three.

The study of history needs no justification to educated people. Knowledge of the past may not perfectly predict the future, but provides clues, data, and wisdom to help find optimal pathways to the future.

The late pediatric surgeon and scientist, Judah Folkman (above) was a man of uncommon wisdom and he had this to say when we visited his lab in Boston with a group of students and faculty from Michigan’s Victor Vaughn Society: “If you don’t understand the history and mission of the organization in which you work, at some point you will feel exploited.” Folkman was paraphrasing his chief at the Massachusetts General Hospital, Dr. Edward Delos Churchill, from an internship lecture. The point, in a larger sense, is that it is essential to job satisfaction, in addition to quality work products, that workers understand the history and mission of the place where they work. For those of us in health care, and urology most particularly, our history and mission are inspiring. If someone misses this inspiration, they are somehow stranded in left field.

It is up to all of us in medicine to study and teach our past to our colleagues, to our successors, and to the public. History, however, is no fixed thing. Stories of the past are fungible – new facts turn up and these may or may not turn out to be true. As times change, reinterpretation of the past changes the old stories. Furthermore, all history is connected and no parochial histories, such as those of urology, can omit consideration of the rest of the world – and vice versa. Ian Thompson once proposed we write a book called How Urology Changed the World. This project remains on our bucket lists. By the way, Folkman’s chief, Dr. Churchill, was Mediterranean Theatre Commander for Surgery during WWII, establishing regional blood banks and air evacuation of the wounded. [ED Churchill. Surgeon to Soldiers. Lippincott Williams and Wilkins. Philadelphia, 1972.] [LS King. Book review. JAMA 220:595, 1972.]

Four.

D-Day anniversary is June 6. We shouldn’t forget that day in 1944, not only the particular day, but also the forces that led up to it, its incredible stories, and the world that followed. The politics, deployments, leaders, meteorology, weaponry, heroism, cowardice, teamwork, and duplicity constitute innumerable stories, stories that will change as new facts and analyses come into play and lead to a greater truth.

The iconic photograph above (called “Into the jaws of death”) was taken by Robert F. Sargent, Chief Photographer’s Mate. It shows disembarkation at Omaha Beach of Company E, 16^th Infantry, 1^st Army Division wading onto the beach at Fox Green Section about to encounter the German 352^nd Division. German forces were commanded by General Rommel, who was away from Normandy that day because of his wife’s birthday. D-Day took the Germans by surprise and early signs of the invasion were discounted by Hitler, who was certain that Calais would be Eisenhower’s Allied Operation Overlord landing site. The American 1^st Army, commanded by Omar Bradley, was responsible for both the Omaha and Utah Beach invasions. Two-thirds of Omaha’s Company E became casualties and of the 39 soldiers I count in the photograph, 26 would die or be seriously injured. Overall Omaha casualties were the worst among the 5 sectors that also consisted of Gold, Juno, and Sword under Canada and Britain. Allies landed 156,000 troops at Normandy on D-Day – 34,250 at Omaha. Only Juno and Gold linked up on D-Day, and it wasn’t until June 12 that all 5 beachheads consolidated. Allied casualties on D-Day were at least 10,000 with 4,414 confirmed dead, while German casualties were estimated at 4,000-9,000. If you have not visited Normandy, you should. Bradley was the last of America’s nine 5-star generals. I knew him briefly at the end of his life when I was at Walter Reed Army Medical Center.

Five.

The Pointe du Hoc speech of Ronald Reagan at the 40-year D-Day anniversary was mentioned last month in this posting. This speech was novel for its use of personal stories of D-Day to make that moment in time poignant to the audience. Individual stories build persuasion through ethos, pathos, and logos. My daughter Emily, when she was a Ph.D. student in English, instructed me repeatedly in those three classic modes of rhetoric and I’m finally starting to appreciate them. A story is persuasive when it comes from a credible source (ethos), if it appeals to sympathetic emotion (our mirror neurons yielding pathos), and if the narrative makes sense (logos). The audience must reasonably accept the story and storyteller as believable and honest, as well as agree with its observations or conclusion. Of course not all stories are authentic, although it is expected that the stories and histories of medicine are genuine.

“The United States Army’s clinical histories of medical practice during the Second World War form a significant addition to the literature of medical history,” Quinn H. Becker, Surgeon General of the U.S. Army, wrote. Those words were the introduction to the urology volume, edited by John F. Patton, in Surgery in World War II, produced by the Medical Department of the United States Army. My friend and former fellow here at Michigan, John Norbeck, gave me this book when it came out 30 years ago. [John F. Patton, Ed. Medical Department, Unites States Army. Surgery in World War II. Urology. Office of the Surgeon General and Center of Military History Unites States Army. Washington, DC, 1987.] Becker’s predecessor as Army Surgeon General was Bernhard T. Mittemeyer, my former commander at Walter Reed, fellow urologist, and friend who most recently served as president of Texas Tech University.

Six surgeon general’s later the name Eric Schoomaker pops up for the Army Surgeon General term of 2007 – 2011. Eric was a UM undergraduate who then completed UM Medical School with an additional Ph.D. in genetics. He undertook residency and fellowship in hematology at Duke followed by a distinguished Army career. Eric was our Medical School commencement speaker in 2012, when Jim Woolliscroft presided as dean. UMMS graduation is a major milestone for students and their families and it is also a meaningful ceremony for faculty – when else do you get to recite the Hippocratic Oath in sync with your colleagues? I had to miss it this year due to concurrence with the annual meeting of the AUA and Nesbit Alumni reunion. This year Francis Collins was UMMS commencement speaker, who was also linked to UM Department of Human Genetics as a faculty member under the great Jim Neel. The Collins address featured him singing on the guitar.

Six.

Cornelius Ryan brought D-Day and urology together for me. This Irish journalist covered WWII and turned his reporting into three excellent historical accounts, The Longest Day (1959), The Last Battle (1966), and A Bridge Too Far (1974). When I was a urology resident at UCLA I helped care for a 50-year old patient with metastatic prostate cancer when Ryan’s personal and similar story with the disease was published. Ryan had been diagnosed just he was struggling to begin writing A Bridge Too Far. He had seen a NYC urologist for lower urinary tract symptoms, a prostate nodule was detected, and biopsy was performed. Ryan returned to the office on Fifth Avenue, July 24, 1970 to get the results when the urologist informed him that the biopsy showed prostate cancer and radical prostatectomy was the only hope for “cure.”

“The doctor wants me to have the prostatectomy next week. Such urgency appalls me. I cannot make that crucial decision without more time. Professionally, I have never accepted a single piece of historical data without researching it to the fullest, collecting all the opinions and interviews I could.” [A Private Battle. Published posthumously with Kathryn Morgan Ryan. New York City, 1979. p, 22. Simon & Schuster.]

Ryan wanted more of an explanation, but his questions were rebuffed. Home in Connecticut later that day he began a series of dictations that included the quote above, but never shared these with his wife. Ryan visited experts around the world and obtained more studies and advice, before returning to New York and discovering Willet Whitmore, for whom he developed great admiration and trust. Ryan began radiation therapy at Memorial Sloan Kettering that autumn, yet the cancer spread and continued to disseminate in spite of drug therapy. Kind and compassionate care was evident in interactions with Whitmore and most other physicians, but the initial condescending urologist, botched handoffs, institutional smugness, and healthcare disparities Ryan witnessed, are reported in sharp contrast. Over the next four years, as he struggled with spreading prostate cancer, Ryan completed his book.

After Ryan died in 1976 his widow, Kathryn Morgan, found the tapes in his desk. She had them transcribed, interspersed her own observations and diary notes, and then published the account in 1979 as A Private Battle. I can’t recall how I came to know of the book, but I read it around that time. Somewhere along the line between UCLA, Walter Reed, and the University of Michigan I lost my copy, but after my own radical prostatectomy in 2014 I thought of Ryan, tracked down the book, and re-read it. A Private Battle contains meaningful lessons on health care and rekindled my curiosity about WWII, leading me to Ryan’s other books, followed by Steven Ambrose’s account of Eisenhower, Soldier and President and the newer biography by Jean Smith.

The Ryan papers ended up in the libraries at Ohio University. [Above: Cornelius Ryan at his desk. Photo and copyright by Eugene Cook.]

Seven.

Eisenhower, one of the great generals of history, detested war and recognized the necessity of international cooperation for peace. The deliberate restructuring of Europe after the war, management of tensions with the Soviet Union, and construction of the European Union were meant to bring stability and peace to the world. Peace, however, has been illusive in much of the rest of the planet and furthermore the postwar structures in Europe are unraveling.

Like most of us, Eisenhower had health issues. A knee injury altered his career path and turned him from a high-level football player to a remarkable coach, influencing his ascent to leadership. He began to smoke at West Point, largely as an ironic challenge to the authoritarian nature of the school and became a chain smoker throughout most of his career, particularly during WWII. After the war his doctor told him to quit smoking and he did, “cold-turkey.” Recurrent ileitis, Crohn’s disease, troubled him throughout life. Although he complained minimally, several hospitalizations and one operative procedure were necessary. As a resident I would learn about the “Eisenhower procedure,” namely a bowel resection for localized Crohn’s disease. During the White House years, Eisenhower’s physician was Howard Snyder, the grandfather of my friend and colleague Howard McCrum Snyder at Children’s Hospital of Philadelphia. The younger Snyder recalls going to the White House swimming pool with his grandfather to swim with the president. Eisenhower’s cardiac issues were significant later in his life. A book by Clarence Lasby discusses the 1955 heart attack and makes judgments about Snyder’s management and the concealment of the illness, thoughts that rely on today’s standards of care and transparency. [CG Lasby. Eisenhower’s Heart Attack. How Ike Beat Heart Disease and Held on to the Presidency. University Press of Kansas. Lawrence KS, 1997.] But for Dr. Snyder, Nixon might have had his turn as president before JFK.

Eight.

Since Eisenhower’s days medical practice has changed and tools to address heart disease are enormously different. Eisenhower had bed rest, the EKG, and digitalis. Today we have an armamentarium of medications, surgical bypass, replacement parts, stents, TAVR, electrophysiology ablations, and heart transplants. The scientific cocoon of 21^st century medicine is countered by local workplace problems. These may be matters of patient access, bed capacity, EHR problems, technology constraints, and billing and coding issues.

Although painful for us on the frontline of health care, they are “first world problems” that come into perspective when considering the rest of the world. Journals such as The Lancet frame the global perspective. For example, a recent paper examined the hypothesis that better cook stoves might prevent pneumonia in children under 5 years old in rural Malawi. Unfortunately, the study (a cluster randomized controlled trial) found no benefit. What stuck in my mind, however, was the opening statement of the paper.

“Almost half the world’s population, including 700 million Africans, rely on biomass fuels for cooking (e.g. animal dung, crop residues, wood, and charcoal)… Biomass fuel is typically burned in open fires, often indoors, leading to high levels of air pollution from smoke.” [Mortimer K, Ndamala CB, Naunje AW et al. A cleaner burning biomass-fueled cookstove. The Lancet. 389:167-175, 2017.]

While we dither in our journals and at our professional meetings over trivial first world issues, such as the virtues of robotic surgery versus open surgery or HIPPA compliance in electronic health records, half the world cooks its meals on open fires using dung or other biomass fuels.

Bulgakov brings us closer to that other world. He served his patients to his technical limits, but insecurity due to the inadequate knowledge and tools of his time as well lack of good professionalism role modeling left him abrupt and authoritative to patients and families. Fifty years later the Fifth Avenue urologist of Cornelius Ryan was no kinder. Kindness and consideration of patient preferences are fundamental to the concept of the good doctor, however it seems to have taken federal regulation to drive that sensibility home as MACRA and CAHPS link professional compensation to evaluations by patients.

Nine.

Case reports. Bulgakov’s stories are narratives of actual cases or extrapolated patient experiences and we may never quite know where fact ended and imagination or “artistic license” took over. It doesn’t really matter, because the stories ring true and are constructed artfully although presented as “stories” rather than clinical case reports. Imbued with experience and fact, they are intended as fiction and we judge them accordingly, but well-crafted fiction can illuminate reality, honing a story well enough to let the reader glimpse a portion of the real world and the human condition with greater acuity than before the reader encountered the story. The judgment of whether Bulgakov’s story was true or imagined is not necessarily essential to readers a century later. If the story rings true and we find meaning (and art) in it, then the author has done a good job. Other physician writers have continued this genre, artfully using clinical experiences and stories to expand consciousness and discover truths about ourselves. David Watts, our Chang Lecturer on Art and Medicine next month, is part of that tradition.

Stories intended as clinical narratives, on the other hand, demand absolute truth in the narrative. This is a bedrock expectation. Truth matters greatly in the real world of clinical medicine and in the academic reporting that surrounds it. A clinical story assumes scrupulous adherence to the facts of the matter and, if presented artfully, the report can have great meaning for the reporter and the readers. The value of a good clinical story is neither necessarily less or greater than the value of a reported clinical experiment, series, trial, or metastudy. Scientific experiments or larger clinical studies may ultimately be true or false, but clinical stories will likely remain durable narratives, unless the story was inaccurately reported or its substance misinterpreted. Some iconic scientific studies such as Mendel’s seeds or Semmelweis’s antisepsis experiment remain iconic and continue to instruct new generations of students. The clinical experiences of Morton with anesthesia, Lister with open bone fractures, or Annandale with successful orchiopexy were presented initially as stories – but they were stories that changed the world.

Ten.

Truth is also an expectation in academic humanities and journalism, although it is perhaps more fungible. Political perspective matters and it can put a spin on things. In the Soviet Union, truth was expected to emanate from the political leadership and this paradigm distorted the science, economics, agriculture, and indeed all parts of the nation. For example, the political imprimatur that validated the beliefs of Soviet agronomist Trofim Lysenko had enormous negative consequences for the health and welfare of his nation. [Loren Graham. Lysenko’s Ghost. Epigenetics and Russia. Harvard University Press, 2016] As we approach our big national holiday next month, it’s worth reflecting that the Declaration of Independence is remarkable in human history for liberating people as individuals from governments ruled by particular ideological, religious, or political paradigms. Representational democracy, imperfect as it is, remains mankind’s best hope toward a just, peaceful, cosmopolitan, prosperous, and sustainable world. This is the world that civilized people want to leave behind – a world somewhat better than we found it, granting that sometimes the prospects for this hope seem dimmed. We can tell our stories as historians, biographers, scientists, or journalists. Or we can tell them as artists, philosophers, or fabricators. It is important to discern the difference and to teach that discernment to our successors. Whether by trachea and tongue, pen and paper, or keyboard and internet, stories knit the human fabric together and truth is the ultimate arbiter. Don’t expect data to replace stories, you can support or refute stories with data. You can build stories out of data, perhaps someday using artificial intelligence in robots. But authentic stories will most likely always come from authentic humans.

Postscript

Once the redbuds faded away, the dogwoods (more easily pollinated) and other flowers stepped up their games of attraction.

[Above: dogwood. Below: Bee tongue photo from photomicrography.net, amateurmicrography.net http://www.flickr.com/photos/joeheath/5122105785/]

Thanks for reading What’s New/Matula Thoughts this June, 2017.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts August 5, 2016

Posted by dabloom

Matula Thoughts – August 5, 2016

Summertime field notes, superheroes, and retrograde thoughts.
3975 words

Patient experience. Walking through the Art Fairs last month after great lectures from visiting professors, my thoughts wandered to Matula Thoughts/What’s New, this electronic communication that has become my habit for the past 16 years. It may be presumptuous to think that anyone would spend 20 minutes or more reading this monthly packet approaching 4000 words. Certainly, UM urology residents and faculty are too busy to give this more than a glance, and that’s OK by me. Of the 10 items usually offered I’d be happy if most folks just skimmed them and perhaps discovered one of enough interest to read in detail. Conversely, some alumni and friends hold me to account for each word and fact, and they are enough for me to know that this communication (What’s New email and Matula Thoughts website) is more than my whistling in the wind.

One.

Art & medicine. Luke Fildes’s painting, The Doctor, shown here last month, deserves further consideration in the afterglow of Don Nakayama’s Chang Lecture on Art & Medicine. [1892, Tate Gallery]. The duality of the doctor-patient relationship, ever so central to our profession, has gotten complicated by changes in technology, growth of subspecialties, necessity of teams and systems, and the sheer expense of modern healthcare. As Fildes shows, medical relationships in the pediatric world extend beyond twosomes and this actually pertains for all ages, since no one is an island. That nuance notwithstanding, the patient experience through the ages and into the complexity of today remains the central organizing principle of medicine.

[Dr. Chang & Don Nakayama]

An article in JAMA recently explored the patient experience via the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) Survey. Delivered to random samples of newly discharged adult inpatients, the 32 items queried are measurements of patient experience that parlay into hospital quality comparisons and impact payments. [Tefera, Lehrman, Conway. Measurement of the patient experience. JAMA 315:2167, 2016]

It is unfortunate that health care systems and professional organizations hadn’t previously focused similar attention on patient experience and only now are compelled to investigate and improve it by the survey. We may chafe and groan at HCAHPS, but it reflects well on representational government working on behalf of its smallest and most important common denominator – individual people.

Everyone deserves a good experience when they need health care whether for childbirth, vaccination, otitis, UTI, injury, other ailments and disabilities, or the end of life. If for nothing more than “the golden rule” all of us in health care should constantly fine-tune our work to make patient care experiences uniformly excellent because, after all, we all become patients at points in life. The individual patient care experience is the essential deliverable of medicine and the epicenter of academic health care centers from the first day of medical school to the last day of practice, after which we all surely will become patients again.

Two.

Educating doctors. Last week’s White Coat Ceremony was the first day of medical school class for Michigan’s of 2020. Deans Rajesh Mangulkar and Steven Gay with their admissions team assembled this splendid 170th UMMS class. Unifying ceremonies are important cultural practices and this one is an exciting milestone for students and a pleasant occasion for the faculty who will be teaching the concepts, skills, and professionalism of medicine. Families in attendance held restless infants, took pictures, and applauded daughters and sons. A “doctor in the family,” for most of the audience, happens once in a blue moon, a rare circumstance of joy, and certainly evidence of success and luck in parenting. The attentive audience for the 172 new students entertained only rare social media diversions. Julian Wan represented our department on stage.

Dee Fenner’s keynote talk resonated deeply. She described her career as a female pelvic surgeon and its impact on patients and on herself. Dee talked about the symbolism of the white coat and skewered today’s hype about “personalized medicine”, saying that medicine is always rightly personalized; our ability to tailor health care to the individual genome is just a matter of using better tools. Alumni president (MCAS) Louito Edje said: “This medical school is the birthplace of experts. You have just taken the first step toward becoming one of those experts.” She recommended cultivation of three fundamental attitudes to knowledge: humility, adaptability, and generosity. Students then came to the stage and announced their names and origins before getting “cloaked.”

The ceremony passes quickly, but is long remembered. Students shortly immerse in intense learning, although medical school is kinder today with less grading, rare attrition, and greater attention to personal success and matters of team work.

My favorite “new medical student story” concerns the late Horace Davenport. He had retired before I arrived in Ann Arbor, but remained active in the medical students’ Victor Vaughn Society that met monthly at a faculty home for a talk over dinner. Davenport, an international expert in physiology, was a superb and fearsome teacher as one student, Joseph J. Weiss (UMMS 1961), recalled from the fall of 1957.

“In our first physiology lecture Dr. Horace Davenport grabbed our attention by announcing that the first person to answer his question correctly would receive an ‘A’ in physiology and be exempt from any examinations or attendance. The question was: ‘What happened in 1623? The context implied an event of significant impact to human knowledge. After a long pause the amphitheater echoed with answers: the discovery of America, the landing of the pilgrim fathers, the death of Leonardo da Vinci. Then Nancy Zuzow called out: ‘The publication of William Harvey’s The Heart and its Circulation’. There was sudden silence. She must be right. How clever of her. Of course a physiologist would see this landmark publication as an event to which we should give homage. Who would have thought that Nancy was so smart? Even Dr. Davenport was impressed. He asked her to stand, and acknowledged that she had provided the first intelligent response. ‘However,’ he noted, ‘that publication occurred in 1628.’ No one could follow up up on Nancy’s response. Dr. Davenport looked around the room, sensed our ignorance, realized we had nothing more to offer, and then said: ‘1623 was the publication of Shakespeare’s First Folio.’ He announced that we would now move on and ‘return to our roles as attendants at the gas station of life”,’ and began his first in a series of three lectures on the ABC of Acid-Base Chemistry.” [Medicine at Michigan, Fall, 2000. Weiss, a rheumatologist who practiced in Livonia, passed away in October 2015. Zuzow died in 1964, while chief resident in OB GYN at St. Joseph Mercy, of a cerebral hemorrhage.]

Three.

New Perspectives. Visiting professors bring different perspectives and last month the Department of Urology initiated its new academic season with several superb visitors. Distinguished pediatric surgeon Don Nakayama gave our 10th annual Chang Lecture on Art and Medicine on the Diego Rivera Detroit Industry Murals. [Below: full house for Nakayama at Ford Auditorium]

I’ve been asked what relevance an art and medicine lecture has for a urology department’s faculty, residents, staff, alumni, and friends. Davenport would not have questioned the matter. This year, in particular, the lecture made perfect sense with Don’s discussion of what can now be called the orchiectomy panel in the Detroit Institute of Arts murals. Hundreds of thousands of people have viewed this work since 1933, including the surgical panel that art historians labeled “brain surgery” – a description unchallenged until Don revealed the scene represented an orchiectomy. His Chang Lecture explained the logic of Rivera’s choice.

[Top: Caleb & Sandy Nelson; Middle: Bart & Amy Grossman, Bottom: George Drach]

The day after the Chang Lecture, Caleb Nelson (Nesbit 2003) from Boston Children’s Hospital and Bart Grossman (Nesbit 1977) of MD Anderson Hospital in Houston delivered superb Duckett and Lapides Lectures. Caleb discussed the important NIH vesicoureteral reflux study while Bart brought us up to date on bladder cancer, greatly expanding my knowledge regarding the rapid advances in its pathogenesis and therapy. George Drach from the University of Pennsylvania provided a clear and instructive update on Medicaid coverage for children. Concurrent staff training went well thanks to those who stayed behind from this yearly academic morning to manage phones, clinics, and inevitable emergencies.

[Above: Lapides Lecture, Danto Auditorium]

Four.

Observation & reasoning. Don Coffey, legendary scientist and Johns Hopkins urology scholar, retired recently. Among his numerous memorable sayings he sometimes mentioned an old southern phrase: “if you see a turtle on a fencepost, it ain’t no coincidence.” A tortoise on a post isn’t some random situation that happens once in a blue moon, it is more likely the result of a purposeful and explainable action. (Of course, it is also not a nice thing.) Coffey was arguing for the importance of reflective and critical thinking as we stumble through the world and try to make sense of it, whether on a summertime pasture, in an art gallery, or in a laboratory examining Western blots.

[Above: tortoise sculpture on post. Mike Hommel’s yard AA, summer, 2016. Below: Coffey]

Richard Feynman (above), Nobel Laureate Physicist, offered a related metaphor.

“What do we mean by ‘understanding’ something? We can imagine that this complicated array of moving things which constitutes ‘the world’ is something like a great chess game being played by the gods, and we are observers of the game. We do not know what the rules of the game are; all we are allowed to do is to watch the playing. Of course if we watch long enough we may eventually catch on to a few of the rules… (Every once in a while something like castling is going on that we still do not understand).” [RP Feynman. Six Easy Pieces. 1995 Addison-Wesley. P.24]

Observation, reasoning, and experimentation are the fundamental parts of the scientific method that allows us to figure things out. Feynman’s castling allusion is brilliant.

[EO Wilson at UM LSI Convocation 2004]

E.O. Wilson went further with his thoughts on consilience, the unity of knowledge.

“You will see at once why I believe that the Enlightenment thinkers of the seventeenth and eighteenth centuries got it mostly right the first time. The assumptions they made of a lawful material world, the intrinsic unity of knowledge, and the potential of indefinite human progress are the ones we still take most readily into our hearts, suffer without, and find maximally rewarding through intellectual advance. The greatest enterprise of the mind has always been and always will be the attempted linkage of the sciences and humanities. The ongoing fragmentation of knowledge and resulting chaos in philosophy are not reflections of the real world, but artifacts of scholarship. The propositions of the original Enlightenment are increasing favored by objective evidence, especially from the natural sciences.” [Wilson. Consilience. P. 8. 1998]

Five.

Superheros. Somewhat to our cultural disadvantage our brains are hardwired to favor physical performance, entertainment, and appearances over intellectual leaps of greatness. We celebrate actors, athletes, politicians, musicians, and cartoons far more than great intellects. Worse, intellectuals in many periods of history were deliberately purged.

Coffey, Feynman, and Wilson are real superheroes of our time. Their ideas have been hugely consequential and they individually are role models of character and intellect. Another name to add to the superhero list is Tu Youyou (屠呦呦). My friend Marston Linehan first alerted me to her incredible story and discovery of artemisinin. It is also a story of how the better nature of humanity is subject to the dark side of our species and the nations we let govern us.

Born in Ningbo, Zhejiang, China in 1930 Tu Youyou attended Peking University Medical School, developed an interest in pharmacology, and after graduation in 1955 began research at the Academy of Traditional Chinese Medicine in Beijing. This was a tricky time to be a scientist in Maoist China. Ruling authorities favored peasants as the essential revolutionary class and in May 1966, the Cultural Revolution launched violent class struggle with persecution of the “bourgeois and revisionist” elements. The Nine Black Categories (landlords, rich farmers, anti-revolutionaries, malcontents, right-wingers, traitors, spies, presumed capitalists, and intellectuals) were cruelly relocated to work or forage in the countryside while neo-revolutionaries disestablished the national status quo.

In 1967 as North Vietnamese troops contended in jungle combat with US forces, chloroquine-resistant malaria was taking a heavy toll on both sides. Mao Zedong launched a secret drug discovery project, Project 523, that Tu Youyou joined while her husband, a metallurgical engineer, was banished to the countryside and their daughter was placed in a Beijing nursery. Screening traditional Chinese herbs for anti-plasmodial effects Tu found Artemisia (sweet wormwood or quinghao) mentioned in a text 1,600 years old, called Emergency Prescriptions Kept Up One’s Sleeve (in translation). She led a team that developed an artemisinin-based drug combination, publishing the work anonymously in 1977, the year after the revolution had largely wound down and only in 1981 personally presented the work to World Health Organization (WHO). Artemisinin regimens are listed in the WHO catalog of “Essential Medicines.” Tu won the 2011 Lasker-DeBakey Clinical Medical Research Award and in 2015 the Nobel Prize In Physiology or Medicine for this work.

[Above: Artemisia annua. Below: Tu Youyou with teacher Lou Zhicen in 1951]

Tu_Youyou_and_Lou_Zhicen_in_1951.TIF

Six.

It may be a human conceit to think of ourselves as the singular species on Earth capable of self-improvement. Considering the impact of Coffey, Feynman, Wilson, and Tu among other intellectual superheroes, imagination at their levels seems a rarity in the universe. Yet, any sentient creature wants to improve its comfort as well as its immediate and future prospects, for who is to say that a whale, a dolphin, a gorilla, or an elephant cannot somehow imagine a more comfortable, happier, or otherwise better tomorrow? In anticipation of another day, birds make nests, ants make tunnels, and bees make hives.

We humans have extraordinary powers of language, skill (with our cherished opposable thumbs), and imagination that provide unprecedented capacity to improve ourselves. Accordingly we easily imagine ourselves in better situations, whether physically, materially, intellectually, or morally, and as it is said, if we can imagine something we probably can create it.

Imagination of a better tomorrow is part of the drive for change as we consider our political future, although this can be risky. The intoxicating saying out with the old and in with the new has led to such things as the United States of America in 1776 or the Maastricht Treaty and European Union in 1992. Change, however, does not always produce happy alternatives, as evidenced by the Third Reich, the dissolution of Yugoslavia, the Arab Spring, or Venezuela’s Chavez era. Disestablishment does not predictably improve life for most people. The human construct, at its best and most creative, rests on a fragile establishment of geopolitical, economic, and environmental stability. The status quo that has been established may be imperfect, but is disestablished only at considerable risk.

Representational government and cosmopolitan society seem to be the best-case scenario for what might be called the human experiment wherein various factions of a diverse population come together to create a just social agenda and build a better tomorrow. The threat to this utopian scenario comes from factionalisms and tribalisms that insert narrow self -interests and litmus tests for cooperation into any consensus for agenda. We see this in the mid-east, in the European Zone, and in American presidential election cycles. Generally ignored or forgotten by competing factions and litmus-testers is the worst-case scenario of civil collapse. We experienced limited episodes of this in two World Wars, southeastern Asian catastrophes, central African genocides, Yugoslavia’s dissolution, and the collapse of Syria to name some instances. However sturdy we think human civilization may be, it is only a thin veneer in a random and dangerous universe. Civil implosions of one sort or another occur intermittently in complex societies, however we must become better at predicting them, circumventing them, and most importantly preventing their dissemination. Their catastrophic nature surpasses any sectarian interests or individual beliefs beyond the survival of civilization itself.

Seven.

The Blue Moon, mentioned earlier, is a picturesque metaphor for an uncommon event. It’s actually not random, inasmuch as a blue moon is a second full moon in a given month (or other calendar period), so the next one can be accurately predicted. Since a full moon occurs about every 29.5 days, on the uncommon occasions it appears at the very beginning of a month, there is a chance of Blue Moon within that same month. The next Blue Moon we can expect will be January 31, 2018.

The song is a familiar one. It was originally “MGM song #225 Prayer (Oh Lord Make Me a Movie Star)” by Richard Rogers and Lorenz Hart in 1933. Other lyrics were applied, but none stuck until Hart wrote Blue Moon in 1935.

Nothing is visually different between blue moons or any other full moons. I took this picture (above) of a nearly full moon this June after some trial and error. A full moon is a beautiful thing and can’t help but give anyone a sense of the small individual human context. Friend and colleague Philip Ransley, now working mainly in Pakistan, spent much of his career aligning his visiting professorships around the world with lunar eclipses and lugging telescopes and cameras along with his pediatric urology slides. Receiving the Pediatric Urology Medal in 2001, barely a month after the tragic event of September 11, 2001, he spoke on lunar-solar rhythms, shadows, and their relationship to the human narrative: “… I would like to lead you into my other life, a life dominated by gravity and its sales rep, time. It has been brought home to us very forcibly how gravity rules our lives and how it governs everything that moves in the universe.” [Ransley. Chasing the moon’s shadow J. Urol. 168:1671, 2002]

[PG Ransley c. 2005]

Ransley is currently working in Karachi, Pakistan at the Sindh Institute of Urology and Transplantation, the largest center of urology, nephrology, and renal transplantation in SE Asia. The pediatric urology unit at SIUT is named The Philip G. Ransley Department. [Sultan, S. Front. Pediatr. 2:88, 2014]

Eight.

Ruthless foragers. Earlier this summer a friend and colleague from Boston Children’s Hospital, David Diamond, brought me along for a bluefish excursion off of Cape Cod. These formidable eating machines travel up and down the Atlantic coast foraging for smaller fish. Like many other targets of human consumption, blue fish are not as plentiful as they once were, although they are hardly endangered today.

[From Atlantic States Marine Fisheries Commission]

Just as we label ourselves Homo sapiens, the bluefish are Pomatomus saltatrix. Both, coincidentally, were named by Linnaeus, the botanist who got his start as a proto-urologist, treating venereal disease in mid 18th century Stockholm. His binomial classification system (Genus, species) is the basis of zoological conversation, although genomic reclassification will upend many assumptions. Also like us, the bluefish is the only extant species of its genus – Pomatomidae for the fish and Hominidae for us. Thus we are both either the end of a biologic family line or the beginning of something new. Our fellow hominids, such as Neanderthals, Denisovans, or Homo floresiensis didn’t last much beyond 30,000 years ago, although they left some of their DNA with us. It may be a long shot, but I hope H. sapiens can go another 30,000 years.

[Bove: ruthless foragers]

Like us, Pomatomus saltatrix are ruthless foragers, eating voraciously well past the point of hunger. Their teeth are hard and sharp, reminding me of the piranha I caught on an unexpected visit to the Hato Piñero Jungle when attending a neurogenic bladder meeting in Venezuela some 20 years ago. Lest you think me a serious fisherman, I disclose there’ve not been many fish in between these two.

[one of 4 piranha geni (Pristobrycon, Pygocentrus, Pygopristis, & Serrasalmus that include over 60 species]

Linnaeus gave bluefish a scientific name in 1754, describing the scar-like line on the gill cover and feeding frenzy behavior (tomos for cut and poma for cover; saltatrix for jumper, as in somersault). I learned this from the book Blues, by author John Hersey (1914-1993), who was better known for his Pulitzer novel, A Bell for Adano (1944) or his other nonfiction book, Hiroshima (1946). [Below: Hersey]

Michigan trivia: Hersey lettered in football at Yale where he was coached by UM alumnus Gerald Ford who was an assistant coach in football and boxing for several years before admission to Yale’s law school. Hersey became a journalist after college and graduate school in Cambridge. In the winter of 1945-46 while in Japan reporting for The New Yorker on the reconstruction after the war he met a Jesuit missionary who survived the Hiroshima bomb, and through him and other survivors put together an unforgettable narrative of the event. The bluefish story came later (1987).

Nine.

Today & tomorrow. Today is the start of the Summer Olympics in Rio de Janeiro, Brazil where 500,000 visitors are expected, presumably well covered and armed with insect repellent due to fears of Zika, an arbovirus related to dengue, yellow fever, Japanese encephalitis, and West Nile viruses.
Tomorrow is a sobering anniversary. I was 11 days old, on August 6, 1945, when, at 8:15 AM, a burst of energy 600 meters above the Aioi Bridge in Hiroshima, Japan incinerated half the city’s population of 340,000 people. Don Nakayama wrote a compelling article on the surgeons of Hiroshima at Ground Zero, detailing individual stories of professional heroism. [D. Nakayama. Surgeons at Ground Zero of the Atomic Age. J. Surg. Ed. 71:444, 2014] We reflect on Hiroshima (and Nagasaki) not only to honor the fallen innocents and to re-learn the terrible consequences of armed conflict, but also to recognize how close we are to self-extermination. A new book by former Secretary of Defense, William Perry, makes this possibility very clear, showing how much closer we came to that brink during the Cuban Missile Crisis. [Perry. My Journey at the Nuclear Brink. Stanford University Press. 2016]

Ten.

Self-determination vs. self-termination. Life, and our species in particular, is far less common in the known universe than Blue Moons, it might be said, although those moons actually are mere artifacts of calendars and imagination. Art and medicine are distinguishing features of our species, Homo sapiens 1.0. The ancient cave dwelling illustrations of handprints on the walls and galloping horses, are evidence of our primeval need to express ourselves by making images. The need to care for each other (“medicine” is not quite the right word) is an extension from the fact that we are perhaps the only species that needs direct physical assistance to deliver our progeny. If our species is to have a future version (Homo sapiens 2.0) we will have to check ourselves pretty quickly before we terminate ourselves, through war and genocide, consumption of planetary resources, or degradation of the environment. While representational government, nationally and internationally, may be our best hope to prevent termination we will have to represent ourselves a lot better. That’s a fact whether here in Ann Arbor, in Washington DC, in China, Africa, Asia, or Europe.

Tribalism resonates with many deep human needs and it has gotten our species along this far, but H. sapiens 2.0 will have to make the jump from tribalist behavior to global cosmopolitanism. Sebastian Junger, a well-known war journalist, has written a compelling book that explores the human need for a sense of community that he describes by the title, Tribe. While we need better sense of community in complex cosmopolitan society, we cannot accept primitive tribalism, sectarianism, or nativism of exclusivity that exacerbate conflict among the “isms.” Tribalism cannot create an optimal or even a good human future whether the version is Brexist or ISIS, paths retrograde to human progress and the wellbeing of humanity in general.

[Girl with Pearl Earing, Vermeer, c. 1665, & viewers at Mauritius Museum, The Hague]

Reflections on art and medicine lead to cosmopolitan and humanitarian thought and behavior. Humanistic reflection, shared broadly, should track us more closely to a utopian scenario, rather than to catastrophe that is only a random contingency away.

[Anatomy Lesson of Nicolaes Tulp. Rembrandt, 1632. Mauritius Museum, The Hague]

Thank you for reading our Matula Thoughts.

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

Matula Thoughts March 4, 2016

Posted by dabloom

DAB What’s New March 4, 2016

The March of time, money, & art

3923 words

One. Time flies, but sometimes we have to slow it down. Today would have been March 5, but for a corrective leap year adjustment. This necessity is proof of the slightly imperfect alignment of humans to nature – we meter out our seasons and years with great reliance on lunar and solar cycles, yet our calendars and clocks can’t quite match heavenly reality. Nevertheless, since Robert Hooke’s anchor escape device, human ingenuity has been measuring time with increasing precision. Pocket watches, developed in the 16^th century, were the most common personal timekeepers until military trench watches (pocket watches with lugs for a strap) became popular around WWI, proving more practical than a watch in a soldier’s pocket. The wristwatch quickly came into fashion. Today cellphones threaten wristwatches for top position in personal timekeeping, although wrists are contesting the matter with physical activity trackers that also monitor time, pulse, and even messaging alerts. Whether by wrist, phone, or clock most people are compelled to track time at home and at work. In the health care environment time measurement has come to sharply impact patient care and residency education due to intense attention on clinical throughput and duty hour regulations. [The pocket watch shown above is a rare Donald Mozart three-wheel mechanism watch made over 150 years ago.]

Two. Time is money, it is often said. If I need furnace repairs this winter, a repairman will reacquaint me with that fact. This is also true for legal services, cabs, baby sitters, or employees in your business. Ultimately, because most of us are employees for someone or some organization, we each have a personal stake in the belief that time equates to money. Healthcare used to be somewhat different, being a professional service in which the service was valued as a parcel of work rather than a unit of time. A doctor’s visit, for example, was charged as the actual “visit” with the time factor accounted for indirectly. New knowledge and technology added complex services to the toolkit of health care and the relative value unit (RVU) joined the language of medicine. Urethral catheterization, for example, takes less time and expertise than radical cystectomy, a fact now accounted for in the charges or RVUs. The physician work RVU for catheterization (CPT 51702) is 0.5 (although after facility expenses and malpractice expenses are factored in the total RVU grows to 0.87 to 2.0 depending upon whether the work is done in a hospital or an office). For open radical cystectomy with urinary diversion (CPT 51590) the physician’s work RVU will be 36.33 and the total RVU including facility and malpractice expenses will be 55.66. The assignment of an RVU number to robotic cystectomy is under discussion. Radical cystectomy is one of the most technically difficult and risky operative procedures, with significant mortality, morbidity, complex postoperative care, and the highest postoperative readmission rates. In terms of work (preoperative, operative, postoperative, and global exposure) and liability it is easily more than the “equivalent” of 36.33 urethral catheterizations, in my opinion as someone who has performed both procedures. If it is your urethra getting catheterized, of course you want skill, kindness, and attention to the process. Yet, to equate the effort of 36 catheterizations to a single radical cystectomy is like comparing 36 bicycle rides to flying a Boeing 787 or Airbus A380 full of passengers across the Pacific Ocean. Both take skill and both carry some risk, but the differences are enormous. [Data thanks to Malissa Eversole & Irene Gundle]

Just as all procedures are not equal, neither are all clinic visits the same, although less disparity pertains. One new patient visit may be fairly straightforward with discovery of a simple problem defined as ICD-10 code X and perhaps a distinct solution proposed in the form of CPT code Y. If such simplicity had pertained for all my patients and clinics over the years, life would have been easier although less interesting. Some clinic visits are especially challenging, taking deep concentration and probing examinations and conversations that are not always easy. Occasional clinic encounters are excruciating, with unwilling kids, angry parents, painful social circumstances, and no clear solutions. Yet even these complex occasions are gifts of a sort in that they test our mettle and make the other encounters, by contrast, satisfying and sweet.

Most of us understand the need to steward resources, standardize work as much as possible, and create efficiencies to meet payrolls and manage our mission at large. However, a sharp focus on clinical throughput, with standardized 15-minute encounters and checklists that must be obeyed, runs counter to our values, counter to patient satisfaction, and counter to the excellence we espouse. Still, our eyes stray to clocks on the walls, (although it is a mystery why they are so often wrong) or watches on our wrists, the latter being easier to consult unobtrusively than cell phones and are more accurate than those wall clocks.

Three.

Ben Franklin wrote “time is money” in Advice to a Young Tradesman, written by an old one although the idea has a far older provenance. It is fitting that Ben is featured on our largest circulating currency denomination (since 1969 when larger bills were retired). The Franklin has become the international monetary standard and is worth more than its weight in gold if you figure that the bill weighs around a half a gram and with the price of gold at $1200 per ounce that comes to about $40 per gram or $20 for a Ben Franklin. The US Bureau of Engraving and Printing says that the average C-note remains in circulation about 7.5 years before replacement due to wear and tear. The new bill, with its anti-counterfeiting technology, costs about 12.5 cents to produce, compared to 7.8 cents for the older version (shown above) before 2013. Curiously, and I think dangerously, some people are calling for eliminating this “high” currency note, as humanity seems to be placing its faith in electronic monetary transactions. [Getting rid of big currency notes. NYT Editorial Feb. 22, 2016]

In health care, the concept that time is money applies across all nations and health care systems. In corporate U.S. health care, clinic visits are set in many places at 15 minutes of “face time” with physician, nurse practitioner, or PA. In the NHS of the United Kingdom 10 minutes is a common standard. In third world countries, any such face time might be a rare occasion unless you have cash in hand. Facilities and staff cost money and health care expenses need to be covered by some source, so it seems rational to measure and ration time as well as physical commodities. Facing off against such reality, however, is the nearly universal belief that health care is a natural human right and that its best delivered at the individual level by professions (and, now, teams of professionals).

Time value of money is a financial calculation that dates back to the early days of the School of Salamanca formed by Spanish and Portuguese theologians in northwestern Spain around the first half of the 16th century. (The old city of Salamanca in Castile and León is a UNESCO World Heritage Site.)

Martín de Azpilcueta (1491-1586), pictured above, was an early member of this important school of thought. This Basque canonist and theologian was an innovator of monetarist theory and it was he who allegedly conceptualized the time value of money in the sense that the present value (PV) of a sum of money equals its future value (FV) given a specified rate of return (r) divided by 1 plus r. That is if the Department of Urology gives the University of Michigan Clinical Enterprise $1,000,000 for new capital projects and assumes a rate of return of 7% (the typical interest rate for a savings account in days not so long past) then the FV at 10 years will be $1,700,000, assuming the original sum and the yearly interest returns remain intact. In other words, a million dollars today if invested in those circumstances could be worth 1.7 million dollars in 10 years. Of course, this is not quite as good as that historic savings account at 7% where the interest was compounded annually, in which case the future value at 10 years would be a little over $1,967,000. That is the difference between an annuity and a savings account. Darwinian forces have propelled financial markets to increasingly creative and complex devices, such as credit default swaps that gained recent attention in the film The Big Short, or the more recent contingent convertible bond (CoCo) that exchanges risk for the ability to suspend payment, convert the bond into equity, or write it off totally.

In 1748 Franklin wrote: “Remember that Time is Money. He that can earn Ten Shillings a Day by his Labour, and goes abroad or sits idle one half of that Day, tho’ he spends but Sixpence during his Diversion or Idleness, ought not to reckon That the only Expence; he has really spent, or rather, thrown away Five Shillings besides.” [Courtesy Kate Woodford at Yale University, Papers of Benjamin Franklin Project]

This is the innate paradox of academic medicine: since clinical revenue sustains the enterprise, every part of the day diverted to education, research, and administration is costly, lacking proportionate revenue. Nevertheless, education, research, and their administration are essential to our mission. For a healthy academic clinical department these other parts of the mission consume a minimum of 20% of a clinician’s effort and the ability to support those efforts comes from endowment, institutional support, and the overachievement of clinical faculty in terms of clinical productivity.

Four. As scarce as face-time may be for patients and the professionals who provide it, that time and attention within those moments are polluted by the mandatory processes of electronic health record systems, third party payer requirements, and demands of “meaningful use” documentation. I call your attention once again to the crayon drawing of a doctor’s visit by an 8-year old girl featured on a JAMA cover article in 2012 by Elizabeth Toll and contrast that to any of the many other artistic renderings of this ancient professional service from Renaissance painting to Normal Rockwell. Something seems to have changed. (Interestingly, Rockwell’s family doctor doesn’t seem to be wearing a watch.)

[Above: detail from The Family Doctor by Norman Rockwell 1947; Below: The cost of technology. JAMA 307: 2497, 2012. Elizabeth Toll. © Thomas C. Murphy, MD]

Five. Time piece manufacturing came to Ann Arbor 150 years ago when Donald J. Mozart moved here just after the stockholders of the MoZart Watch Company in Providence, Rhode Island fired him as superintendent. Mozart’s three-wheel watch had proven unsuccessful and the new superintendent replaced Mozart’s design with a conventional movement and renamed the firm the New York Watch Company. Mozart improved his 3-wheel design in Ann Arbor, but was able to produce only about 30 movements before closing up operations four years later in 1870.

He sold the manufacturing equipment to the Rock Island Watch Company for $40,000 cash plus $25,000 in stock and gave away the existing watches to stockholders and friends. One of these was recently sold at auction in NY [Introductory illustration & below: Bonhams Auction 21971 12 June 2014 Lot #1128 A very rare gold filled open face ‘chronometer-lever escapement’ watch Signed Don J. Mozart Patent Dec. 24, 1868. US$ 20,000-25,000].

Mozart was still living in Ann Arbor as of May 14, 1873 when he filed a patent from here, but died four years later in 1877 and was buried at Forest Hill Cemetery (as was Rensis Likert, discussed last month on these pages).

Six. A noteworthy and thoughtful artist, Evelyn Brodzinski, when asked her definition of what constitutes the stuff we call “art” replied, “Art is anything that is choice.” This idea stuck with me and I often quote her at our speaker introductions during the annual Chang Lecture on Art and Medicine each July during the Art Fair. This phrase came to me again when I read Hugh Solomon’s retirement letter this past December. With his retirement, urological manpower loses one of its most excellent physicians and surgeons. Retirement was a difficult decision, Hugh noted, but his timing seemed right: “I have been lucky to have interfaced with so many wonderful people who have taught me the value and sanctity of life. Everyone has a story to tell if you are prepared to listen.”

Stories, however, are getting bypassed in modern healthcare. With the systematic tendency to measure service in terms of time and time in terms of money, today’s electronic health care record systems force stories into checklists. Listening to stories is harder than filling out checklists. While these tendencies chip away at our ancient profession we can fight the trend. When we make a choice to listen, as Hugh advocates, clinical medicine becomes an art.

Seven. Art & medicine. In 1936 Sir Henry Wellcome’s will established the Wellcome Trust in London to advance medical research and the understanding of its history. If you visit that city the Wellcome Trust is a wonderful place to spend a morning or afternoon perusing its collections and exhibits. An article last year in JAMA by Jeremy Farrar, Director of the Wellcome Trust, discussed the role of this organization in the world today. [Farrar. Science, medicine, and society. A view from the Wellcome Trust. JAMA. 313:2315, 2015] The trust expends more than $1 billion dollars yearly in biomedical sciences and biotechnology “interrogating the fundamental processes of life in health and in sickness and using that knowledge to develop ways to promote well-being and to diagnose, treat, or prevent disease.”

Farrar makes the point that while science is essential and wonderful, its implementation in medicine and society is not guaranteed. He references Semmelweis and Snow, who in the mid-nineteenth century provided theory and supporting evidence that certain diseases were transmitted by dirty hands, yet conventional wisdom of the time rejected the idea. Farrar writes: “…their stories reveal that scientific evidence is not enough to improve medicine: social and cultural factors are vital as well… Because the Trust appreciates the importance of the history and social contexts of medicine, it also supports research across the medical humanities, social sciences, and bioethics, as well as funding for artists and educators to engage the public with research.”

We health care professionals revel in science. Scientific ways of thinking have brought us a verifiable understanding of life, health, and illness as well as new technologies to enhance health and mitigate disease. Yet as Farrar tells it, science is not enough. History, social contexts, and values must always frame the science, as well as inspire and deploy it. In the consilience of human knowledge, as EO Wilson explains, science is but one facet of the art of Homo sapiens.

Eight. Chang Lecture on Art & Medicine. In 2007 our Department of Urology began an annual lecture in honor of the family of Dr. Cheng-Yang Chang, an esteemed Nesbit Alumnus who joined our faculty when Urology was a small section of the Surgery Department. Dr. Chang was our first faculty member to focus on pediatric urology. Coincidentally, his father was a highly acclaimed artist in China during its turbulent mid-Twentieth Century years. A number of his paintings are housed in the University of Michigan Art Museum where you can also visit the Shirley Chang Wing, named in honor of Dr. Chang’s late wife. The couple had two sons. Ted Chang, a University of Michigan and Nesbit alumnus like his dad, practices urology in Albany New York. Ted is a first class urologist and educator. Hamilton Chang, a fellow UM man, is an investment banker in Chicago, a leader in Michigan’s alumni organizations and a cornerstone of our urology fundraising efforts.

This year’s Chang Lecture will be given by Don Nakayama, a pediatric surgeon and expert on the Diego Rivera Murals you can find at the Detroit Institute of Art. The Surgery Panel on the upper left hand corner of the south wall has been described by art historians as “brain surgery,” but after personal investigation Don discovered that the art historians were not quite right, anatomically. The actual panel, in fact, depicts an orchiectomy, an operative procedure far more in tune with Rivera’s theme, as a committed socialist, of the emasculated worker. Don discussed this in a paper in The Pharos, [Summer 2014, p. 8].

[Above: south wall. Below: surgery panel]

If you plan to visit the Ann Arbor Art Fairs this July, consider setting aside an hour to join us at the Chang Lecture on Tuesday, July 21 at 5 PM in the UM Hospital Ford Auditorium. You can hear Dr. Nakayama, meet him at a reception after the talk, collect some CME credits if you are a physician, and have your parking ticket stamped. Not a bad deal, I submit.

Nine. The art of humanity extends from the earliest moments of assisting childbirth, caring for lacerations, splinting fractures, counseling sufferers, and painting on cave walls, to today’s robotic surgery and technological entertainments such as the new Star Wars, if you accept the proposition that art is any deliberative human action or construct. This new iteration of Star Wars successfully expands the story of a distant galaxy and the force that binds it. A business school professor at Washington University St. Louis explored the narrative and proposed that an economic force binds the distant galaxy as well, thus brightening the dismal science. [http://arxiv.org/format/1511.09054v1]

The dark side of the dismal science was evident in another current film – The Big Short. I’d read the book by Michael Lewis, who showed in lucid detail how the housing and credit bubble collapse in 2008, known also as the subprime mortgage crisis, was predicted. This catastrophe quickly expanded into a major stall of the world economy, that is still under repair. The astonishing thing is that the prediction was not made by economists, the big banks, the big accounting firms, universities, Nobel Laureates, bond rating companies, regulatory agencies, or “the market” itself. The prediction was made by an oddball physician who analyzed publicly available data and discovered the “obvious” flaw in complex mortgage securities. Astonishingly, none of the experts was so smart and the sad, sad reality is that none of them was doing their job competently. This story begs the question: how can so many smart people be so dumb? It’s an astonishing story and a very cautionary tale of reliance on experts. If course we have to trust experts, but we also have to verify that trust constantly in real time, by listening to diverse and even oddball opinions and insisting upon honest broker regulation and competition.

The physician who figured this out was Michael Burry, a UCLA economics graduate, Vanderbilt MD, and Stanford neurology resident. His main interest, however, was investing and even as a resident had acquired a reputation for success in value investing. He left residency to invest full-time and in November 2000 he started Scion Capital. As Lewis told the story, in the first full year of Scion when the S&P 500 fell 11. 88%, Scion’s fund was up 55%. This was no Bernie Madoff effect, the Scion success was real, verifiable, and durable. Value investing is based on the idea of buying an asset that appears underpriced according to an analysis of some sort. The analysis may recognize some fundamental flaw in the current price of the asset based on historical factors, operational data related to the company, information about its market and competitors, or expectations concerning the future. In some ways this is a complex extension of the thinking of Martín de Azpilcueta. Burry extended the idea by betting against the future value of money through an insurance mechanism called the credit default swap.

Burry was not looking for “a short” rather was actually seeking good long term bets. In 2005, however, his analysis of national lending practices in 2003 and 2004 indicated to him that a subprime mortgage bubble would collapse in 2007. He persuaded Goldman Sachs to sell him credit default swaps against certain subprime deals. The rest is history, as well as excellent cinematography.

[Illustration: Lamro, on Wikipedia, Credit Default Swap. Burry is the blue box, Goldman Sachs is the black box. The par value of the asset was its high value at the time of the credit default deal.]

Ten. March, now that we are a few days into it, has its own stories. March 1 is the meteorological beginning of spring, although that may not be so apparent here in Ann Arbor. March 20/21 is the astronomical beginning of spring in the Northern Hemisphere or autumn in the Southern. The month is named for the Roman God of War, Mars, who was also the guardian of agriculture. This was an odd conjunction since it is not immediately apparent that the pursuits of war and of agriculture are similar. On the other hand, if you believe that the best defense is a strong offense, the idea makes some sense and in Roman times the month Martius marked a new season of farming and military campaigns. In addition to competence on the land and in battle, legend also ascribed to Mars some competence in the urological sense, as his relationship with the Vestal Virgin, Rhea Silvia, produced twin boys, Romulus and Remus, the mythical founders of the city of Rome. Even beyond the reproductive outcome, Mars was generally viewed as a paragon of virility, with no issues of low testosterone. Martius was the start of the Roman yearly calendar until as late as 153 BC. Russia held on to this start date to the end of the 15^th century, and Great Britain and its colonies (even us in America) used March 25 as the beginning of the calendar year until 1752 when the Gregorian calendar was adopted. March is American Red Cross Month.

March 13 marks the shift to Daylight Savings Time. Ben Franklin has been claimed as originator of daylight savings time, but in fact the solid proposal came from George Vernon Hudson who died 70 years ago (5 April 1946). Born in London he moved to New Zealand with his father and became a respected amateur entomologist and astronomer. His daytime job in Wellington as post office clerk gave him time after work to study and collect insects. It was said that this was the impetus for his idea to maximize daylight in winter times. In 1895 he gave a paper at the Wellington Philosophical Society proposing a 2-hour daylight savings time shift. Hudson was a member of the 1907 Sub-Antarctic Islands Scientific Expedition. The daylight savings idea was slow to catch on and New Zealand’s Summertime Act wasn’t passed until 1927.

[Left: Hudson in 1907 on expedition. National Library of New Zealand. Right: Willett in 1909, J. Benjamin Stone Collection, Birmingham Central Library.]

Daylight savings occurred later to another Briton, home builder William Willett (1856-1915). Riding his horse one summer morning he observed many household’s blinds still drawn, indicating the inhabitants were still asleep and missing much of the day. He began to advocate for an official way to extend daylight and the British Summer Time became law in 1916, although Willett died just before it went into effect. (Trivia: Willett’s great-great-grandson is Chris Martin of the band Coldplay.) Today, daylight savings time methods are utilized throughout much of the world.

[Wikipedia. Blue – DST used, Orange – formerly used, Red – never used]

If March came in like a lion we hope it exits sheepishly after a bit of collegiate athletic madness. We also will be having a departmental retreat at the end of the month. Before closing out this message, let me return briefly to Ben Franklin, printer, inventor, author, postmaster, diplomat, and urethral catheter expert. In 1752 he designed a flexible silver catheter for his brother John who was suffering from bladder calculi and it is likely that, living to age 84, Ben used it himself.

Thanks for reading What’s New and Matula Thoughts.

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

Matula Thoughts August 7, 2015

Posted by dabloom

Fair weather, formicidae, fables, and funambulism

3415 words

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

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

[Michigan Stadium from Ann Arbor Golf Outing]

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

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

[EOW by DAB 2002]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

David A. Bloom, MD

Department of Urology, University of Michigan Medical School

Ann Arbor

Matula Thoughts July 3, 2015

Posted by dabloom

Matula Thoughts July 3, 2015

Independence, PGY1s, peonies, & art.

3673 words

1. It’s July and peasants farm and shear sheep outside the protective walls of a castle in the beautiful panel of the renowned 15^th 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 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.

[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.

[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.

[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.

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

[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.

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

7. 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.

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

[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.

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

[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.

[Julian Wan, Khaled Hafez, Ganesh Palapattu]

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

David A. Bloom

	Nancy Rhodes on Expectations and epistolaries
	dabloom on Expectations and epistolaries
	Nancy Rhodes on Expectations and epistolaries
	John Barry on Politics, as usual?
	dabloom on Expectations and epistolaries

matulathoughts

For centuries the matula was a tool to investigate disease. We use this metaphor for our collection of observations and brief essays from David A. Bloom MD, Department of Urology at the University of Michigan.

Art

December

Quilting bees and blues

Sunrises, sunsets, & summer imaginations

Birthdays, graduations, and centennials

Spring and all

Matula Thoughts June 2, 2017.

Matula Thoughts August 5, 2016

Matula Thoughts March 4, 2016

Matula Thoughts August 7, 2015

Matula Thoughts July 3, 2015