October incongruities and congruities.

 

Matula Thoughts 

Oct 5, 2018

October incongruities & congruities.
3813 words

 

One.

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

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

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

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

 

 

Two.

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

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

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

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

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

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

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

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

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

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

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

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

 

Three.

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

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

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

 

Six.

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

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

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

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

 

Seven.

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

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

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

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

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

 

Eight.

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

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

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

 

Nine.

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

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

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

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

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

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

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

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

 

Ten.

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

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

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

 

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

Castling

DAB Matula Thoughts Nov 4, 2016

 

Matula Thoughts Logo2

3975 words

Preface. This monthly communication from the University of Michigan Department of Urology & David A. Bloom is usually sent by email or posted on line at matulathoughts.org on the first Friday of each month.

huron

One.  

Autumn has been spectacular at Michigan Urology academically and around Ann Arbor visually. Seasonal changes on the Huron River were up to high expectations as leaves colored out and birds headed south. You don’t have to travel far outside of town to see crop harvesting has wound down, while distracting political signs along the roads are highlighting our national political schizophrenia. [Above: Huron River near Wagner Road. Below: Waterloo Road east of Chelsea, Michigan]

silo

 

Nestled in the Midwest, we were spared Hurricane Matthew that hit Haiti, Florida, Georgia, and the Carolinas in October. The biggest regional surprise was the overtime World Series victory of the Chicago Cubs over the Cleveland Indians, both teams having contested well. Births and other happy events also perked up this season, but we suffered losses. Madeline Horton, secretary of Jack Lapides and mother of Suzanne Van Appledorn (wife of Carl Van Appledorn, Nesbit 1972) passed away last month a few weeks short of her 100th birthday. Madeline was our urology librarian, a job largely obviated by the internet. I fondly remember her gracious welcome when I joined the University of Michigan Section of Urology in the early years of Ed McGuire’s leadership.

Final rules for the Medicare Access and CHIP Reauthorization Act (MACRA) went into effect last month, instituting the Quality Payment Program (QPP) that begins its first performance period 58 days from now, by my count. This will significantly change the basis of physician payment and the rules are entrenched so deeply in federal regulation as to be practically bullet-proof from the impending presidential election or other short-term political processes. By November, it is pretty clear that another calendar year is coming to an end and it’s time to start serious planning for next year. Of course as a department of urology specifically, and as a large academic health center more generally, our planning has been on going in earnest for considerably longer than the past few days. Emerging out of many years of restricted capital investment in facilities and regional relationships we are in an unprecedented growth mode to more optimally fulfill our mission. This has been the first year of our new organizational paradigm for the University of Michigan Health System in which Executive Vice President for Medical Affairs of the University, Marschall Runge, added the Medical School deanship to his portfolio. A Health System Board along with Health System President, David Spahlinger, will manage the growing enterprise of hospital groups, medical practice, ambulatory clinics, regional affiliations, and other entities that have evolved to carry out our mission. These are good structural changes and superb individuals for the challenges ahead.

Our mission derives from our foundation as a public medical school in 1850 and is similar to the mission of all other medical schools, although the University of Michigan has long described itself as one of the “leaders and best”, a phrase that history shows we can rightly claim, for the most part. The mission is framed around three components – education, patient care, and research – deployed in that order as our medical school grew, adding its own contained hospital in 1869 and soon thereafter some of the world’s definitive basic science departments and research laboratories.

 

 

Two.  

Silos of expertise necessarily accrued as the medical school and health care center in Ann Arbor grew more complex with the result that the overall management became increasingly disconnected from the loci of expertise at its many workplaces. The gemba, a Japanese term related to the Lean Process Methodology of the Toyota Corporation, describes where work is performed – the workplace. As Toyota, and later Detroit automotive manufacturing came to understand, microeconomic gembas understand their products, customers, and processes better than higher-level managers or accountants. Process improvement, value creation, efficiency, customer satisfaction, and employee satisfaction are best arbitrated “where the work is done” (i.e. the gemba) rather than in distant offices by managerial accounting.

Oddly, just as forward-thinking western businesses are embracing lean process thinking, large health care systems and governmental organizations are more rigidly holding on to managerial accountancy with its concomitant archipelago of cost centers. Of course any organization needs to understand and mitigate its costs, but lean process experience has shown that efficiency and value are a natural result of letting the gemba work as an organic community, rather than forcing its functions by the levers of managerial accounting. [Below: going home from work, a Diego Rivera mural detail – Detroit Institute of Arts]

dsc03595

Anyway, back to the triple mission: the University of Michigan Health System exists to educate the next generation of physicians and scientists, to expand the knowledge and technology base of health care, and to do these things in a milieu of cutting edge clinical care. The central organizing principle at play, that is the essential deliverable (and moral center) is kind and excellent patient-centered care, as we describe it in our department.

The future in healthcare will depend on our ability to weave silos together and innovate, creating new ideas, devices, and methods. In a larger sense innovation is the ability to find better solutions for the needs of a changing environment.

 

 

Three.          

Leadership.  A recurring aspiration of the University of Michigan is that it produces the “leaders and the best.” That phrase is functionally adjectival as with the leaders and the best engineers, teachers, athletes, lawyers, nurses, chemists, or physicians, for example. The leaders and best is less meaningful as a noun, for what does it really mean to be “the best” if not the best of some particular thing. The same holds true for leadership, in my opinion. The aspiration to be “a leader” as a generality carries a bit of a selfish sense with it, whereas the aspiration to lead one’s team to do its job well or otherwise fulfill its mission is more socially virtuous. The difference is perhaps one between the captain of a football team versus travelling CEO’s who jump among companies to exercise their managerial or accounting gifts. Without deep knowledge and investment in a particular organization, an itinerant leader is unlikely to inspire most organizations and its people to achieve their best social destiny. Another way to look at this is whether the leader’s primary goal is to be “the boss” by leading, managing, and controlling employees to achieve organizational targets, in contrast to a goal of helping the organization achieve an optimal state for its stakeholders.

What does a urology department need in a leader? I submit that first and foremost it needs someone who loves and practices urology robustly; former dean Allen Lichter once said  – “for such a person patient care is a moral imperative, not something that is important enough unless it interferes with research.” Second, a clinical department needs an individual who understands the organizational mission and its history – these two things are inseparable, requiring more than just lip service to be truly known. Third, we require someone whom the faculty, residents, staff, and other stakeholders trust. Fourth, the department needs a person who can read the changing environment and find opportunities within it. Other attributes may be valued according to the specifics of each department, institution and moment in time, however “celebrity leadership” by itself should not be high on the list of qualities sought.

 

 

Four.                 

bruxelles_manneken_pis        

Until it fails, people don’t appreciate the beauty of a competent urinary system. Urologists are the essential attendants at that particular service station of life, but the necessity of professional detachment renders us susceptible to underestimating the angst and vulnerability of urologic patients. Finding the right balance between empathy and detachment is a personal matter, arbitrated by daily experience to the extent that we are influenced by our medical practices, role models (real and fictional), and general observations in life. To the extent that we pay attention to the real world around us and to the creative arts, we improve our practice of medicine.

Creative arts matter to medicine. The portrait of Dr. John Sassall by Berger & Mohr in A Fortunate Man, was an artful mix of empathy and detachment. The doctor had sufficient detachment to do what he needed medically for his patients, but retained unusual empathy for their social and economic comorbidities, even to his personal detriment.

In the visual arts for hundreds of years urinalysis, depicted by uroscopy flask (the matula), was the main symbol of medicine indicating the central importance of urine examination to understand disease. After 1816, when Laennec invented the stethoscope, the matula lost its place as the popular symbol of the medical profession. The stethoscope is certainly a less indelicate and a sturdier symbol than a glass urine flask. Imagine Gray’s Anatomy with the matula.

In literature Shakespeare was precocious in recognizing the fallacy of mistaking a clinical test for the actual patient when in this scene from Henry IV Falstaff asks a messenger what the physician thought of his uroscopy specimen:

“Sirrah, What says the doctor to my water?

He said, sir, the water itself was a good healthy water;

But for the party that owned it, he might have more diseases than he knew for.”

Visual art has only rarely portrayed urinary function. One example, the statue Manneken Pis (Little Man Pee, in Dutch. Above: Wikipedia illustration) designed by Hieronymus Duquesnoy the Elder around 1618-1619 has been stolen numerous times and the current version, dating from 1965, stands in Brussels. It is dressed in costumes according to a published schedule managed by “Friends of Manneken-Pis,” but I don’t know if University of Michigan colors have adorned it yet. Other versions of the statue exist regionally and in more distant sites in the world. Notice the arching back of the confident lad making his momentary mark on the world in front of him.

Depiction of urinary tract dysfunction in art is even less common than that of normal function. As common as dysuria and stranguria are for us humans, it’s rare to find them represented in the creative world. The Wayfarer, by Bosch, shows a man with the hunched-over posture typical of urinary distress, relegated to the central background of this curious painting. The painter, who died 500 years ago, lived in the historic low countries now called the Netherlands where he no doubt observed that characteristic posture often, as we do today in restrooms around the world.

the-wayfarer-large

[Hieronymus Bosch. Above: The Wayfarer. Below: voiding detail.]

bosch-detail

The impact of nocturnal enuresis showed up in All’s Quiet on the Western Front, where a young soldier suffered with that burden.

My point is that creative arts sharpen our perception and groom our mirror neurons to make us better attendants at life’s service stations.

 

Five.              

Castling. A few months ago this column referred to Richard Feynman’s metaphor related to mankind’s persistent search for central organizing principles, namely our curiosity to discover rules that govern the universe. He noted that, as we observe the “chess game of the world” and try to figure out how it works, every now and then “something like castling” occurs and blows our minds. That particular chess move is so far out of the box with respect to the other orderly rules and procedures of the game that it is, indeed, something of a miracle in that environment. (For chess aficionados the term rook may be preferable to castle, although castling sounds more appealing than rooking.)

castmove

It is human nature to seek rules. Prehistoric tribal priests, Ionian philosophers such as Aristotle, and recent scientists such as Feynman sought central organizing principles and rules. Unlike the explanations of the village priests, today’s principles of math, physics, chemistry, and biology are testable and verifiable or refutable. We have some ideas of why and how inorganic material things need to flow or seek equilibrium – principles of physics and chemistry govern their existence and fate. It is more of a mystery why biological things need to grow and humans, in particular, need to know things. No one has figured out, without invoking magical or religious paradigms, why our particulate niche in the universe is such as exception to what we perceive as the second law of thermodynamics. Perhaps our material, biological, and intellectual exception to the expanding and entropy-seeking universe is that strange miracle of “castling.” Bob Seger and The Silver Bullet Band expressed it more poetically in the 1980 song Against the Wind.

alaska

[Cosmic castling. Copper River. Kenai Peninsula, Alaska. Summer 2015]

 

 

Six.

It may seem an overstatement of human optimism to believe in the principle that the world you imagine is the world you are most likely to create, but a single person can have remarkable impact; Joan of Arc, Harriet Tubman, Abraham Lincoln, and Mahatma Gandhi are just a few examples. The impact of a single person, just as likely, can be darkly retrograde and numerous examples quickly come to mind.

Scientific thinking and modern technology have given mankind unprecedented tools to change the world with Albert Einstein and Steve Jobs as two of a myriad of other players. If you imagine a kind and just world, you will likely try to live by and spread those attributes. If you imagine a dog-eat-dog world and display that vision to those around you, that may likely become the reality you experience and leave behind. The possibility that a given leader can be good or bad for humanity might appear statistically random, that is stochastic, in terms of probability. On the other hand, if we carry the theme of castling to the idiosyncratic human experiment, it may not be so far-fetched to suggest that our genetic and epigenetic construction has built in a predilection to favor good over evil, making an individual more inclined to do the “right” rather than “wrong” thing at a given moment. That is, the elements leading up to a given personal decision are built upon individual upbringing, world-view, personal needs, perceived needs of our clan, and hope for the future. Adding all these elements, our prevailing human nature favors doing good, in the stoichiometric sense, most of the time.

 

 

Seven.

Where American health care will go next is unclear, no matter how the presidential election turns out next week. Problems abound in health care. The interface between patient and provider filling up with busy work and costs that distract from quality, safety, value, or satisfaction. Third party payers, regulators, public policy (even if well-intentioned) add an immense amount of “stuff” to be done before, during, and after the so-called patient encounter. While we prize innovation and the rewards of a free society, egregious exploitation of American healthcare consumers by industry seems to be getting worse and fuels demands for significant change. The EpiPen disgrace from the Pennsylvania company Mylan is only one of the many recent examples of human elements gone bad [JAMA 316:1439, 2016]. Why call out that one bad example among so many? My reason is simply that Mylan has made themselves such an easy target because they have been so sociopathically greedy.

Our urology silo has been a good one locally and internationally, by and large. This is evident now in the midst of the residency selection process wherein we advocate for our particular training program in Ann Arbor, our specialty having attracted many of the best and brightest of this year’s senior medical students. My colleague and friend Mike Mitchell once called urology (pediatric urology, in particular) “a lovely specialty.” We practice at the cutting edge of technology, we improve patient lives, we fix things that are broken, we have the gift of long relationships with patients, and we generally get along well within our professional arena. As a medical student and resident myself, years ago, the attributes and role models of urology attracted me into the field – and these features of our profession continue to attract the superb students and residents to follow us.

Healthcare is changing and the urology of tomorrow will differ from what I experienced in my career. We have already transitioned from roles as independent urologists such as that of our predecessors Hugh Cabot, Reed Nesbit, and Jack Lapides. Our work to educate, treat patients, and expand the knowledge base of urology requires subspecialization and teams, large teams that transcend clinics, offices, department, and operating rooms. The complexity of science, technology, and healthcare delivery made this change inevitable, with marketplace pressures and regulatory actions accelerating change. The fee-for-service that largely defined health care over the past century is being rapidly displaced by alternate payment methodology, with a sharp focus on value and performance in play today. These were vague terms in health care until recently. Value and performance metrics in other endeavors have achieved growing visibility, so we shouldn’t be surprised to find them crossing over into health care. Michael Lewis’s Moneyball brought these terms to popular attention for baseball in 2014, with the movie in 2011, and healthcare was bound to follow. No doubt some sense of player value governed Theo Epstein in breaking the curses of the Red Sock and Chicago Cubs with their World Series droughts of 86 and 108 years, although it’s unlikely he discovered a novel set of useful metrics.

 

 

Eight.

Value & performance. A paper in JAMA last month demands attention. Vivian Lee et al from the University of Utah offered an original investigation with the lengthy title “Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.” [JAMA 2016; 316(10): 1061-1072] A matching opinion piece in the same issue by Michael Porter and Thomas Lee offered glowing support: “From volume to value in health care”. [JAMA 2016; 316 (10): 1047-1048] While it is clear that value and performance measures will be tools to replace the American fee-for-service paradigm, the details in the Utah study are important, in particular the idea of an “opportunity index” that allows healthcare teams to understand their costs and develop lean processes that improve not just costs, but also quality, safety, and that once-vague attribute value. If leading health care centers believe in a world of value-based healthcare, such a world surely can be created. That world, however, will largely be built on the special skills of specialties and the complex teams of future medicine, wherein urologists with their singular skill sets that will likely always be prized.

 

 

Nine.

Stainless steel, eggs, & sperm. Innovation is a fundamental characteristic of biology, and randomness is always in play. At the cellular level we see innovation from the random errors of genetic transcription and the utilitarian retention of the changes in these DNA sequences when they provide a particular advantage, so one could argue that random chance lies behind all things that happen. Choice, however, somehow slips into play with life. Even low levels of cellular organization make choices and, by extension purposefully innovate in their lives. Nematodes (round worms) and flatworms, such as C. elegans and planaria, seek comfort and food as they move above their microcosms to discover opportunities or deterrents. Their actions are purposeful with deliberate directional choices as opposed to random Brownian motion. Each move is original in its own way, exploring new territory or retreating from threats. In the larger animal kingdom we see choice in behaviors of vertebrates, and hominids have taken choice and innovation to entirely new levels.

One hundred years ago Harry Brearley figured out a way to improve the quality and value of gun barrels. Gun performance deteriorated quickly after use because of barrel corrosion from moisture and gases after combustion, so Brearley considered variety of additives to create steel alloys with better resistance and found chromium most effective. This was already being used in the manufacture of steel for airplane engines, but one particular variant alloy had been difficult to examine microscopically because the etching processes used to prepare the samples for examination were far less effective than usual. The corrosion resistance problem for engine manufacturing proved to be a solution for gunsmiths.

Human innovation continues to advance even more remarkably. At our recent Nesbit meeting, Sherman Silber (Nesbit 1973) presented innovative work in reproductive medicine showing how pluripotent stem cells derived from skin cells can create eggs and sperm with full reproductive potential in normal mice.

 

 

Ten.              

jiffy-silos

Silos. Silos are disparaged glibly in modern organizational discourse, but we owe them better appreciation. Some silos are storage vaults for coal, cement, or salt while others are biologic factories. Grain elevators, for example, store and ferment grain to produce silage for animal feed. Early farmers figured this out, probably noticing it by accident. After harvesting, clover, alfalfa, oats, rye, maize, or ordinary grasses are compressed in a closed space and after a brief aerobic phase, when trapped oxygen is consumed, anaerobic fermentation by desirable lactic acid bacteria begins to convert sugars to acids. Volatile fatty acids (acetic, lactic, butyric) are natural preservatives, lowering pH and creating a hostile environment for competing bacteria. Some microorganisms in the process produce vitamins such as folic acid or B12. Ever since the early days of farming indigenous microorganisms conducted successful fermentation, although modern farms utilize select strains of lactic acid bacteria or other microorganisms more efficiently. Because fermentation produces products that bacteria consume silage has less caloric content than the original forage, but the tradeoff is worthwhile due to the preservation and improved digestibility.

Thinking about silos, it seemed natural to take a trip to Chelsea, Michigan where the family-operated Chelsea Milling Company has been making baking mixes since 1930. Mabel White Holmes created the first prepared baking mix in the United States and her grandson, Howdy Holmes, presently runs this company of 300 employees producing 1.6 million boxes of products daily. Mabel White Holmes originally marketed her biscuit mix as “so easy even a man could do it” and Jiffy Mix with its memorable blue logo became one of America’s classic brands. Chelsea Milling makes and markets 19 mixes distributed to all 50 states and 32 countries. The Jiffy Mix corporate philosophy is employee-centric, much like Zingerman’s Community of Businesses and (we believe) the Department of Urology at the University of Michigan in the recognition of how silos build a community. The Jiffy Mix silos provide dry storage for wheat, while the people that work at the company provide the fermentation that makes and innovates superior products within a lean culture of thoughtful communication and collaborative decision-making. This is biologic castling.

wh-balcony

[Next occupant?]

Whether for storage of salt or biofactories for silage, silos are ultimately useful only when working together as parts of farms and communities. This an analogy holds true in the political arena, where consensus is as important as victory. Our national and international communities suffer from self-righteous siloism. Current political rhetoric lacks dignity and respect to the point of ugliness, although the most corrosive disrespect is the a priori claim that the American political system is rigged, whether by one party, the media, or another nation. It is nonsense to be outraged that other countries are into our emails and elections – that’s exactly what we do as a nation and indeed it is the business of large nations to gather intelligence on competitors and get a thumb on the scales when possible. If our candidates say foolish things and our firewalls are weak then we should own the blame. With 4 days to our next national elections, this incivility of discourse is a short slippery slope to civil instability, which will not be good for anyone. The effect on healthcare will consequential and international scientific media as influential as The Lancet have taken the unprecedented step of hosting a US Election 2016 website: www.thelancet.com/USElection2016.  Aside from parochial concerns such as healthcare, ultimately what will matter most for all of us on the planet after November 8 will be financial market and geopolitical stability – all other concerns pale in comparison.

leaves

[October driveway]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts November 6, 2015

DAB Matula Thoughts November 6, 2015

Seasons, Movember, Nesbit reunion, the dimensions of academic medicine, politics, feline lives, & other disparate thoughts

3452 words

 

Nov leaves

[Self portrait with dog. Nov 8, 2013]

 1.    Shadows are longer in November, days are colder, and it gets dark noticeably sooner as 2015 winds down. Autumn foliage, so spectacular this season, is detaching from the trees and recycling on the ground. Most of us are getting ready to hunker down and bundle up for the business of winter ahead as we begin to contemplate 2016. We meter out our lives in seasons and cycles, so with November we enter a sort of fin de l’année, playing off on the French term for the end of a century. Fin de siècle most notably applies to the end of the 19th century, an era around the 1880s and 1890s that was only well understood decades later when historical perspective could account for its significance. The photo below shows Michigan medical students and the hospital in 1880 on a cloudy late autumn day much like today. Their big news would have been the election of James Garfield as president.

Old Hosp - fall  

[UM Bentley Library. Med students in front of hospital c. 1880]

This was the UM Medical School’s 31st season. The 1880 class, recently graduated, was already practicing medicine throughout the state and beyond. The medical school curriculum had transitioned from a 2-year set of lectures to a 3 and then 4-year program of graduated instruction with laboratory and patient care experience. Today when you walk from our “new” main hospital (it was new in 1986) to the Cancer Center you will pass the class of 1880 picture showing 60 students including 24 women, by my count. Only 4 of the men have moustaches or beards that became so fashionable a decade later (when you continue to view the pictures) and will be more common this month in November due to the world-wide Movember Movement.

UMMS 1880

A decade later in the 19th century fin de siècle on a similar autumn day these Ann Arbor newsboys are getting ready to hawk the morning papers. That year was midway between presidential elections of Grover Cleveland (first term) and Benjamin Harrison. Newsboys are gone, their jobs made obsolete by technology and nowadays people get their news via NPR, television, or smartphones. Urologists, however, have had Darwinian persistence in the human workforce and technology has actually expanded their reach and role.

Newsboys Pose c 1890

[AA newsboys 1890. I can’t give credit to the photographer who obtained this image without a lot more investigation, but after 135 years I figure this must be “fair use.”]

The medical school and hospital have changed much since then and now in our 167th season the signature educational product of our academic medical center has expanded from medical students alone to include residents and PhDs who collectively outnumber the students two to one. Our mission of education, clinical care, and health care discovery remains unchanged since that fin de siècle, but to fit that mission to today’s world we are re-organizing our medical school and hospital under the single aegis of an Executive President for Medical Affairs and Dean, Marschall Runge. The success of this structural change in terms of the optimization of our mission will depend upon three major variables: the operational details currently under construction, the people selected to execute those details, and the productivity (clinical, educational, and scholarly) of our health care enterprise as a whole.

Political rhetoric continues to heat up this month even though major voting is a year away. The U.S. elections are held on the Tuesday after the first Monday of November and the president is elected in even-numbered years at 4-year intervals, so November 8, 2016 will be a big decision point. The contest today looks stranger than ever with providential outsiders competing against highly seasoned and lightly seasoned professional politicians. The consequences of our elections will roll out to residency training programs, medical record systems, and payment methodologies of the not-so-distant future. More importantly, the consequences will be reflected in geopolitical stability and the international economy.

 

 

 2.     The initial urology experiences for most medical students come during third year rotations and fourth year electives when students take clerkships or subinternships at their home schools and visit other places that attract them. At Michigan we had over 350 actual applications for our 4 residency positions. The applicants are clearly the best of the best, although excellent medical school performance and test scores do not automatically equate to great residents, teammates, superb urologists, and Nesbit alumni. It is our job to transform our selected applicants through 5-6 years of residency and subsequent fellowships into extraordinary urologists, educators, and innovators.

The personal statements of our candidates are articulate, show amazing personal accomplishments, and often reflect on the attractions of urology, especially the ability to fix distinct problems with technical wizardry. Yet, I worry how this generation will do with the distractions of the mounting numbers of comorbidities of patients that complicate their “urology issues.” Will urologic detachment blind our next generation of urologists to the inevitable co-morbidities of their patients?  Conversely, will patient comorbidities distract young physicians from urologic-decision making or immobilize them to necessary action? How do we teach our successors to understand and even seek out comorbidities so as to attend to their solutions whilst doing the “urology”? Will the growing administrative burdens, including the mandates of the electronic record and duty hour restrictions, further exacerbate their detachment?

As I was reading transcripts, writing letters of recommendation, and thinking about this new season of applicants, I began to reconsider the characteristics we expect of ourselves as people, physicians, urologists, and educators. Seven key attributes seem to apply equally to residents as well as our best selves. To my list of the seven essential attributes for an excellent urology resident I added a bibliography:

A. Kindness. (P. Ferrucci: The Power of Kindness)

B. Authenticity. You are whom you seem to be. (HG Frankfurt. Two books: On Truth, On Bullshit)

C. Cosmopolitanism (KA Appiah: Cosmopolitanism)

D. Curiosity (EO Wilson: Consilience)

E. Literacy. (S Fish: How to write a sentence)

F. Teamwork & leadership. (DJ Brown: The Boys in the Boat) 

My little list may or may not prove useful for a “book club.” Although we don’t have time for this in the 80-hour weeks “allowed” for resident education, perhaps our best trainees will pursue this list or one like it, surreptitiously off the grid, for “extra credit.”

 

 

Nesbit 2015

3.    Nesbit meeting background. Reed Miller Nesbit was the first official head of urology at Michigan. His teacher, Hugh Cabot, had arrived here in late 1919 to lead the Surgery Department and in short order also became medical school dean. Cabot, a genitourinary surgeon of international stature at this time, was such a catch for the university that the regents gave him the president’s house to live in until he got settled. Nesbit and Charles Huggins were Michigan’s first 2 urology trainees, and Cabot seemed to have trained them well. Cabot’s innovative ideas and outspoken nature offended many and he was fired by the regents in 1930.

Nesbit was then named official head of urology within the Surgery Department and he soon became a pivotal figure in American surgery. Huggins focused on prostate cancer research, developed his career largely at the University of Chicago, and earned a Nobel Prize in 1966. Our Nesbit Society was created in 1972. Faculty, UM urology trainees and UMMS students who got their urology start here, but trained elsewhere, are members of the Nesbit Society.

Residency training is an intense period of work, study, and friendships that reverberate for a lifetime. It is a fact lost on lay people and many in the academe that residency training is the career-defining stage of medical education and the signature product of an academic medical center. It is where the professional knowledge base, values, and skills of the next generation of physicians are forged. Whereas UM has close to 700 medical students and 200 Ph.D.s in health sciences at any time, we have 1200 residents and fellows. [Picture above – day one of Nesbit Meeting 2015 in Sheldon Auditorium; below – day two at North Campus Research Complex]

Nesbit - NCRC

Nesbit 2015. Our Nesbit academic Thursday & Friday were among the best continuing medical education events I’ve experienced and far too much went on to be summarized here. Attendance topped 100 including Tom Koyanagi from Japan, Dave Bomalaski from Alaska, and Jens Sønksen from Copenhagen, along with many other Nesbit alums and MUSIC colleagues from around Michigan. Faculty, resident, and fellows gave superb presentations. Appropos of November, Daniela Wittmann’s talk included details of the worldwide and Ann Arbor impact of the Movember Movement, including significant scientific funding and collaborations for us in AA. Since 2003, Daniela noted, 5 million Movember participants worldwide have raised over $650 million for men’s health, targeted heavily to prostate cancer. Jerry Andriole, our visiting professor from Washington University in St. Louis, gave superb talks on prostate cancer and PSA.

 

Harden et al

Greg Harden, our featured speaker, was extraordinary. [Above from left: Gary Faerber, Mike Kozminski, Dave Burks, Greg Harden, DAB] Long-time psychologist to our Athletic Department Greg spoke about need to fine-tune our personal “critical self-assessments” and extended the idea of fitness holistically to the three domains of physical, mental, and spiritual fitness – noting  the factor of recovery time: the better fit we are, the quicker our recovery from exercise or exhaustion. During the business meeting Gary Faerber, Associate Chair for Education, announced plans for a new resident’s room. While the hospital is footing the half million dollar overall cost, Gary believed that the dinky regulation lockers and minimal amenities should be upgraded so he announced a campaign for Nesbit alums to fund lockers or computer workstations, etc. Many stepped up to the challenge and Jens Sønksen (picture below; Nesbit 1996 and close colleague of Dana Ohl) put us over the top with an amazing gift.

Jens

Julian Wan will be turning over the Nesbit presidency to Mike Kozminski next May at our Nesbit AUA Reception and John Wei will become Secretary-Treasurer. In the Big House Michigan led Michigan State until only the final few seconds when a terrible anti-climactic error cost us the game. No doubt the football team will be doing a thorough post-mortem analysis of that game to look for missed opportunities and analyze mistakes. Just like the rest of the university, the Athletic Department is ultimately an educational unit.

UM vs. MSU  

[Opening of UM vs. MSU game 2015. Lloyd Carr is honored]

 

 

M&M

4.     We too analyze our mistakes and untoward events. The Morbidity and Mortality Conference is a key ritual of academic medicine. Once a month we have a 7 AM Grand Rounds-type meeting where our residents stand up and present serious complications and deaths that occurred in our urology department. Faculty and residents discuss what might have been done differently and what factors contributed to each complication or death. Lay readers should not be surprised – every week deaths are likely to occur in UM hospitals at large and among our outpatient population; several million people a year pass through the doors of our health system, tens of thousands of operative procedures occur, and hundreds of thousands of people with serious illnesses are hospitalized. Our daily work is serious, not just the actual care of patients, but also the education of our successors with the expectation that they will be better tomorrow than we are today in this serious business of healthcare. Just as important as patient care and physician education, no less essential is the need to expand the knowledge base of urologic health and disease, in addition to improving therapies and delivery systems. These are the three dimensions of academic medicine. As specialists we hone in with great intensity on the urology issues presented to us, but must also probe efficiently for the context of the urology problem – the comorbidities of health and life.

 

 

 5.     The lives of patients are far more complex than the urologic problems that bring them to our clinics. With specialization comes our conceit of detachment. Living in an era of specialty knowledge and skills, we specialists concentrate on our specific fields and as urologists these are urologic matters. It is easiest to do this in isolation from all the other stuff around a patient’s life, but of course we also need to listen to them and recognize, for example, such things as sadness about recent loss of a parent, delaying traffic jams on the way to appointments, awful parking situations, or perhaps unusual heartburn experienced after a rushed breakfast to get to the appointment on time. These issues are not necessarily irrelevant to, for example, the small renal mass that brings a patient in to see us, although we still need to focus on that immediate issue – and the clock is running while other patients are checking in and you may shortly be called to the OR. On the other side of the coin we have all referred patients with unexplained problems to other services only to be told dismissively by a colleague: “it is not cardiac” or “it is not GI” or “it is not surgical.” We get exasperated when other doctors fail to “consider the whole patient.”

 

 

6.     Few urological problems, few medical problems of any sort, are isolated conditions. Everyone has lives and comorbidities that complicate the medical conditions under inspection in our clinic. These may be dire social situations, family matters, or other specific medical comorbidities.  A recent Perspective in The Lancet by Todd Meyers of the Department of Anthropology at Wayne State University offers a compelling view of this additional dimension of our health care paradigm.

 “Comorbidity is a clinical and conceptual problem. It is simultaneously a problem of how to describe multiple morbidities – clinically or epidemiologically – and a problem of how individuals themselves conceptualise and wrestle with their polypathia … Through the play of disorder and circumstance (and presentation and expectation), to treat is to capture, to arrest symptoms in a particular moment, but rarely is there enough time or resource to discover where these symptoms fit within the complex lattice that makes up the individual experience of comorbidity.” [Permission of Todd Meyers. The art of medicine. How is comorbidity lived? T. Meyers. The Lancet. 386:1128-1129, 2015]

You and I will never find the perfect balance between truly understanding a patient in terms of comorbidities of life and body and the immediacy of the person’s urologic condition. The art, however, is in our effort to try as we practice medicine patiently, one patient at a time.

 

 

 7.     Comorbidity, as a term and idea, is attributed to internist and epidemiologist Alvan Feinstein who spent his career at Yale School of Medicine. His reputation has been challenged due to some statements during a period of his career when he minimized the negative effects of smoking, even though he had been sponsored by the industry. [Feinstein, Alvan R. (1970). “The pre-therapeutic classification of co-morbidity in chronic disease”. Journal of Chronic Diseases 23 (7): 455–68] It is easy to pile on indignantly to this criticism now, in 2015, but the overwhelming evidence today of the destructive effects of tobacco smoke was not so apparent back then. Later in his career, particularly as editor of the Journal of Clinical Epidemiology, he became more critical of tobacco. Smoking looked cool in the mid-nineteenth century, and the makers of cigarettes naturally tweaked the composition of their product to enhance the addictive features. Ironically, smoking has turned out to be a major contributor to today’s medical comorbidities.

Feinstein, born in Philadelphia December 4, 1925, died just about 15 years ago (October 25, 2001). He obtained bachelor’s, master’s, and medical degrees at the University of Chicago, where he probably interacted with former UM trainee Professor Charles Huggins. In spite of that likely intersection, Feinstein chose internal medicine for a career and trained at the Rockefeller Institute, becoming board certified in 1955.  [Picture from Yale Bulletin & Calendar Nov. 2, 2001] After a few years at what would later become the NYU Langone Medical he moved to Yale in 1962 and became founding director of its Robert Wood Johnson Clinical Scholars Program in 1974.

Feinstein 

 

 

Freedom_from_Want

8.     November brings Thanksgiving to mind. The Norman Rockwell painting Freedom from Want (discussed on these pages last March) had its debut on March 6, 1943 as a Saturday Evening Post cover. This was number three in his Four Freedoms series of oil paintings inspired by Franklin Delano Roosevelt’s 1941 State of the Union Address. Rockwell started this particular painting the previous Thanksgiving in 1942, depicting actual friends and family at the table. We are too comfortable today to feel as viscerally about the four freedoms as Roosevelt, Rockwell, and most Americans did during the darkest days of WWII or as the world’s 60 million refugees must feel today, but we should beware that our comfort rests on only a thin veneer of civilization. As specialists we are also sometimes too comfortable in our professions. We enjoy not only the four freedoms of Roosevelt (freedom of speech, freedom of worship, freedom from want, and freedom from fear), but also freedom to choose one’s work, in our case the specialty of urology. Board certifications and hospital credentialing processes define our scopes of practice, while varying degrees of personal detachment allow us to focus specifically on urologic disorders and their treatment.

 

 

9.     On this particular day in history two now-obscure events left countless social and physical comorbidities reverberating still today. In 1965 Cuba and the United States agreed to an airlift for Cubans who wanted to come to the United States. When the Cuban revolution began in 1959 the U.S. government initially reacted favorably to it, but after hundreds of executions and Fidel Castro’s embrace of communism relations soured and by 1965 the Communist Party was governing Cuba. Amazingly, Castro is still around, having survived as Cuba’s leader parallel to 11 American presidents for 16 terms of office. By 1971, 250,000 Cubans had made use of this program. Only now, 50 years later, do we find signs of improvement in relations with that nation of 11 million people only 90 miles away from Key West, Florida. A second historic coincidence occurred exactly 40 years ago on the other side of the Atlantic. The Green March was a strategic mass demonstration in November 1975, coordinated by the Moroccan government, to force Spain and General Franco (ailing despite recent recovery from a serious bout of phlebitis) to hand over its colony, the disputed, autonomous Spanish Province of Sahara. Some 350,000 Moroccans advanced several miles into the Spanish Sahara territory, escorted by nearly 20,000 Moroccan troops and met very little initial response from either Spanish forces or the Sahrawi Polisario Front, an independence movement backed by Algeria, Libya, and Cuba which was fortified by Soviet arms. The Spanish Armed Forces were asked to hold their fire so as to avoid bloodshed and they removed mines from some previously armed fields. Nevertheless, the events quickly escalated into a fully waged war between Morocco, Mauritania, and the Polisario, once Spain left the territory. The Western Sahara War, as it came to be known, lasted for 16 years. The color green was incorporated to invoke Islam. A cease-fire agreement reached in 1991 remains monitored by the UN Mission for the referendum in Western Sahara (MINURSO). What these two events have in common is the disruption of people’s lives when colonialism, regionalism, and independence movements collide and become playing grounds for larger international proxy conflicts. Sound familiar?

 

 

 10.    November refers to the number nine in Latin, a quantity recalling the alleged lives of a cat. Reflecting back over the shoulder of human time, you can’t help but think that our species has been testing the limits of our existence with far more numerous close calls than a cat’s. The Cuban missile crisis was just one close call, among other instabilities around the planet from Africa, to the mid-East, and in far too many other places. The feline proverb  dates back at least to Ben Johnson’s play written in 1598, Every Man in his Humor. William Shakespeare performed in that play and then used a similar phrase a year later in his own play Much Ado About Nothing: “What, courage man! What though care killed a cat, thou hast mettle enough in thee to kill care.” The actual intent of the word care, was worry or sorrow, but somehow over the intervening centuries curiosity became the perpetrator of the cat’s demise. Possibly the belief in 9-lives is related to the ability of cats to land on their feet. In fact their spine is more flexible than that of humans; while like most mammals cats have 7 cervical vertebrae, they have 13 thoracic, 7 lumbar, and 3 sacral vertebrae. We humans have 3-5 caudal vertebrae fused into an internal coccyx, but cats have a variable number of caudal vertebrae in their tail.

English_tabby_cat

[English tabby cat. 1890. Popular Science Monthly Vol. 37] 

 It is also curious, if we may re-employ the term without penalty, that while cats may have 9 lives and often have amazing moustaches (that remind us of Movember throughout the year), dogs unequivocally remain mankind’s best friends.

 

Thanks for considering our Matula Thoughts once again.

Best wishes for Movember, 2015.

David A. Bloom

 

 

Matula Thoughts October 2, 2015

DAB What’s New October 2, 2015

Matula Thoughts Logo2

Change, colors, chloroplasts, mitochondria, & detachment

3048 words

 

Mich green

1. Michigan’s green landscape is changing now that October is here with the deciduous ritual of autumn colors creeping south at the rate of about 200 miles per week. Autumn colors in Ann Arbor, however, are not just botanic. October brings us deep into the heart of football season when maize and blue attract intense scrutiny. Legend has it that a group of Michigan students decided that the school colors should be azure blue and maize, but school officials didn’t make it official until 1912. Curiously the actual shades of maize and blue differ between the University at large and the Athletic Department.

Sincock Seats

[Above: Fall colors in Ann Arbor. Big House night game from Craig & Sue Sincock’s box. October 11, 2014.  Below: UM seal with distinctive azure blue, courtesy Brad Densen]

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2. Physicians once paid great attention to the green world, as plants were a prime source of medicines. This changed in the later 19th century, when modern medicine evolved with its verifiable conceptual basis of biochemistry, pathology, physiology, microbiology, pharmacology, etc. Before then medications fell into the area of study known as materia medica and botanic knowledge was a necessity for doctors. Leaves are green, by the way, because the dominance of chlorophyll masks out other pigments. As leaves age, green chlorophyll degrades into colorless tetrapyrroles, so that yellow xanthophyll and orange beta-carotene pigments take over visually, although they had been present throughout the leaf life cycle. Red pigments, the anthocyanins, are synthesized de novo as chlorophyll becomes degraded. After the non-green colors show up detachment and recycling of this year’s leaves soon follows.

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[Biochemistry refresher: Pyrrole, the five-membered ring shown above (C4H4NH), a colorless volatile liquid, was first detected by F.F. Runge in 1834 as a coal tar derivative. Pyrrole is a component of chlorophyll, other botanic pigments, as well as the red cell porpyrin heme, a co-factor of haemoglobin. Four pyrroles assemble to make up a porphyrin, and these molecules allow  numerous color options.]

I happened to see my first leaves of the season fall in early September when I was in Nijmegen, Netherlands at the semi-centennial celebration of the splendid urology unit of Radboud University.

Leaves

[Above: detachment in Nijmegen 2 weeks ago.

Below: What we look forward to this month: Ann Arbor foliage October 2014.]

Barton tree

 

3.  Change is an apt theme right now as it surely is in the air for health care. Coalescing organizations, new regulations, untried payment systems, intensifying competition, narrow networks, tiered access, new technologies, fantastic and fantastically expensive new drugs, are among the factors behind the unprecedented change. These changes are more than seasonal or market changes and they are putting things that we cherish at risk, namely the three dimensions of academic health care – education, research, and quality clinical care. Clinical care is the primary resource engine for academic health care centers (AMCs). This aspect of our mission is the mitochondria of AMCs, providing not just the context for education and research, but also the bulk of its sustaining funding. Furthermore, clinical care is the moral epi-center and the essential deliverable of AMCs.  While American health care is not perfect, it isn’t better in most other places on the globe. Consider the options – in a perfect world how would you manage and fund a piece of society and the economy as necessary, complex, and large as health care? A purely market driven system would leave out a huge chunk of the populace and would not service the interests of the public health at large. Purely governmental systems are perpetually under-resourced, funded at the whim of rotating politicians, bureaucrats, and accountants. Canada, at this moment in time, seems to be the remarkable sole exception to this seemingly natural law. I’ve worked in England’s National Health System (NHS) twice in my life, and am somewhat familiar with its ups and downs, but that natural tendency of impoverished dependence on central governmental funding and accountancy management is inescapable. The NHS was intended to be the exclusive source of health care for the British public, but a growing private sector of health care in the U.K. provides some balance and competition.

 

4.   My friend Karin Muraszko, chair of our Neurosurgery Department, recently gave me a book called Do No Harm by Henry Marsh, a neurosurgeon in London. I read it cover-to-cover and thought it remarkable. The value of appropriate and necessary detachment for a surgeon is one of three things that jumped out at me from the book. The second is that natural law I mentioned whereby a national health system budgeted by politicians and managed by accountants does not serve patients, families, health care workers, or other essential stakeholders well, or kindly. The third point is that duty hour restrictions enforced by national agencies (governments, regulatory organizations, professional groups, or payers) are not conducive to professional education, competence, or expertise, much less excellence. The 48-hour work-week for neurosurgical trainees in Europe might be compatible only with a 15-20 year period of training, but not much less. While a few older surgeons like Henry Marsh are still around, and perhaps an occasional excellent new neurosurgeon might emerge miraculously from the sad current European training paradigm, I fear for the next generation of patients with neurosurgical problems on the other side of the Atlantic. Even more frightening is the thought of the subsequent generations of neurosurgeon-educators that will emerge. For them duty hours, accountancy management, and patient “hand-offs” may trump the sense of professionalism and duty they might vaguely recall having seen in the vanishing breed of Henry Marsh.

 

5.   One of the most important rituals of academic medicine is the selection and education of our successors and just now we are in the midst of this with a new cycle of applicant interviews for our residency. Residency training is the career-defining stage of medical education and one could claim it is the signature educational product of an academic health center, usually exceeding (sometimes by more than twice) the time spent in medical school. I don’t think laymen or our central campus friends fully understand this reality.  During our residency training at Michigan young physicians learn the state-of the-art clinical skills of urology, its conceptual basis, professionalism, teamwork, and leadership. They develop the habits of lifelong learning and teaching. When I finished training in general surgery at UCLA, I became a member of the Longmire Society, just as our residents in urology at Michigan become members of the Nesbit Society. The Longmire Society certificate includes a motto that features the words: detachment, method, thoroughness, and humility.

Longmire

These were presumably the ideal characteristics of a Longmire-type surgeon, and indeed suited “the boss” well. Yet the inclusion of detachment as an ideal characteristic puzzled me at first and didn’t seem quite right as it seemed to imply a lack of compassion and empathy, although I’ve since come to understand the importance of detachment with more subtlety. As I write these thoughts the irony of the term “duty hours” strikes me: duty vs. duty hours. Of course, no one can be “on duty” all the time, but people like Henry Marsh, in addition to their sense of necessary detachment, carry their professional duty with them as best they can throughout their careers day-by-day and night-by-night. The on-and-off duty switch is not flicked frequently. Professionalism, nevertheless, carries with it some danger: we become self-righteous in our jobs and professions. We tend to define the limits of our duty more according to the convenience of our job descriptions than by the needs of the public. This does allow us some detachment, but sometimes more for our own sakes than the sake of those among the public who might want our help or kindness.

 

6.   Change is in the air locally at our own academic health care center in Ann Arbor. We are modestly reorganizing our structure and governance, and a new strategic planning process is in play. As Dwight Eisenhower said: “… plans are worthless, but planning is everything.” (Remarks at the National Defense Executive Reserve Conference. 11/14/1957) We urgently need to figure out how to balance our growing patient population with our mission, with our facilities, and with the changing landscape of health care. At the September 17 Regents Meeting changes were made to our organizational structure that should help us build and execute a strategy that fits us well and secures our success in the brave new world of academic health care. Effective January 1, 2016 Marschall Runge, will add the role of medical dean to his position as Executive Vice President of Medical Affairs. David Spahlinger will become president of the clinical enterprise (a new name for this entity is pending; we have been using the term UM Health System) and Executive Vice Dean of the UMMS for Clinical Affairs. New positions will be recruited for a chief academic officer, a chief scientific officer, and a chief information officer for the academic medical center. A chief value improvement officer has been hired by Dr. Runge. Tony Denton will be the Senior Vice President and COO of the clinical enterprise. [Below: Tony & Marschall] Doug Strong, our former CEO of the hospital and most recently VP for Finance & Business of the University will be retiring after a long run of distinguished service.

Marschall & Tony

 

7.   300px-Julius_Sachs  Born on this day in 1832 was Julius von Sachs, in Breslau, Kingdom of Prussia. We might not be inclined to celebrate his name now 183 years later, but we really should. A curious youngster, probably just like you once were, he had an early interest in natural history, which in 19th century Europe and North America was the term used for what today we call science. With a Ph.D. from Charles University in Prague in 1856 he embarked on a career in botany. His academic career took him from Dresden to Bonn to Freiburg and then to the University of Würzburg as chair of botany in 1868 where he spent the rest of his career, contributing greatly to the study of plant physiology. He is credited with the discovery of the chloroplast, a subcellular unit in which the chlorophyll pigment packs energy from sunlight into molecules ATP and NADPH while freeing oxygen and producing carbon dioxide. Like mitochondria, chloroplasts have their own DNA and are believed to have been inherited from an ancient ancestor, a photosynthetic cyanobacterium eaten up by ancient eukaryotic cell that happened to be hungry at a certain lucky moment far back in time. A similar moment of ingestion happened somewhere around then when another hungry cell devoured an organism that turned out to be the ancestor of mitochondria, the internal engine for animal cells. Chloroplasts and mitochondria are the resource engines for all life forms beyond the most primitive ones.

 

8.   I have a friend who sometimes says: “Change is inevitable, but progress is optional.” [On Wikipedia the quote is attributed to Tony Robbins, motivational speaker.] Health systems nationally as well as here locally in Michigan are in the midst of change, but we are hopeful that our local changes, here at least, represent progress. The demand for our clinical services in Ann Arbor is growing. I remember not many years ago our health system clinic visits were well under a million a year and we thought we were busy. Our most recent fiscal year (FY 15) produced 2,123,746 visits – representing a 6.1% increase just over the previous year, of which return visits constituted 4.7% and new patients were up 15.3%. The pressure on our exam rooms, faculty, staff, operating rooms, and hospital beds has been painful. We need to manage our health care enterprise better to fulfill the expectations of patients and our community, as well as to enhance our educational and research missions. This cannot be viewed from an accounting mentality as a zero sum game with one mission at the expense of another, but rather as a synergistic triad, with the clinical mission as the moral center, the context for education and research, as well as the prime economic engine.

 

9.   My first box of crayons when I was a toddler offered a half dozen colors and I didn’t notice or imagine at the time that many more colors could exist. If you glance quickly at a rainbow or the light from a prism that’s not such a naïve belief.

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[Reflection from a glass door on the floor of my in-law’s house in Waterloo, Iowa. Summer 2015]

However, over time in childhood my crayon boxes got larger with many more colors than I could have imagined. A 64 pack of crayons was astonishing discovery for me.

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Nowadays, kids on their iPads can sort through literally thousands of colors. This in turn should be no surprise because on inspection the spectrum of light is not an array of discrete quanta of color variations (at least, not that we know!) – it is in reality a spectrum. This increasing complexity derived from our attention is matched throughout the world today in the increasing number of cable TV channels, the proliferation of presidential candidates, the growing number of health care specialties and focused areas of medical practice, the 10-fold increase medical diagnostic codes effective this year (ICD-10), expanding sectarian conflicts, and gargantuan expansion of worldwide refugees.

 

10.   The 50th anniversary of Nijmegen Urology was a wonderful celebration they shared with international guests from Japan to Italy to Ann Arbor. It gave me some ideas about the upcoming anniversary of Michigan Academic Urology in 2019. My inclusion in Nijmegen was due to the luck of having Wouter Feitz, their chief pediatric urologist, spend three months with us in Ann Arbor many years ago. Nijmegen, the oldest city in the Netherlands, is situated on the nation’s eastern edge, next to the German border. Radboud Medical University contains a superb urologic unit that happens to be an epicenter of European Urology politically as well as geographically. There, under Frans Debruyne, the European Association of Urology got its start and now, headed by Peter Mulders, the urology unit continues to excel.

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[Past & present chairs of Nijmegen Urology. Above: Frans Debruyne. Below: Peter & Cindy Mulders]

Peter & Cindy Mulders

The innovative academic celebration was focused around specific patients in the various domains of urology and yet it explored the cutting edges of discovery and therapy. Our pediatric session featured the faculty at Radboud, Wouter Feitz, Barbara Kortmann,  Robert De Gier, and Ivo De Blaauw, with Raimund Stein of Mainz and Mannheim along with myself as guests.

Raimund, Maie-Jose, Wout

[Above: Raimund, Marie Jose & Wout Feitz. Below: Barbara & Robert]

Barbara & Robt

 

Since our session was on the opening day of the meeting, Wout and I skipped the second day to visit the Mauritius Museum in The Hague, on the western edge of the “Low Country.” The newly restored museum, a lovely historic house in the midst of the complex of government buildings known as the Binnenhof, houses Rembrandt’s great Anatomy Lesson of Nicholas Tulp [below], Vermeer’s Girl with Pearl Earring, and The Goldfinch by Fabritius. These great works and others compel thoughtful attention.

Tulp

Every year on the third Tuesday of September, which occurred the following week in the nearby Ridderzaal (Great Hall), the King delivers The Speech from the Throne. Wout and I happened to walk by after the room was set up for the event and on public display.

Ridderzaal

[Ridderzaal]

This Dutch tradition is mirrored in the State of the Union address in the United States, and in the annual State of the Medical School speech at our local level in Ann Arbor. Jim Woolliscroft (seen below), our medical school dean performed this task admirably for nearly a decade, just as Allen Lichter had done as our previous dean. Both were great leaders, colleagues, physicians, and educators. They have my greatest admiration for their work in guiding the UMMS through challenging times. Marschall Runge is amply up to the task for our next big steps as an academic health care enterprise in the new combined role.

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The trees in the Netherlands during my recent visit had just a few patches of autumn colors, although some leaves had already changed enough to detach and fall.

Hague tree

[Above: tree with patch of yellow. Below: early leaves on the ground near Binnenhof]

Hague leaves

From the air as I left the Netherlands the long-lasting and combined effects of those primeval cellular meals of chloroplasts and mitochondria were in full display on the ground below. The green landscape is an obvious credit to the chloroplasts, however the fact that a large percentage of the land, although actually below sea level, is now dry land must be attributed to mitochondrial life forms, especially ours. Thanks to human ingenuity and industry 17% of the Netherlands surface area has been reclaimed from the sea and only 50% of the country’s land is over a meter above sea level. Out of my view from the air and during my brief visit to Holland was the immediate staggering refugee crisis, in Europe below and the world at large. A recent JAMA viewpoint from the UN High Commissioner’s Office on the state of the world’s refugees is worth reading [Spiegel. JAMA 314:445] The UN Refugee Agency counts 60 million forcibly displaced people worldwide at this date and half of them are children. This situation must be charged to the mitochondrial side of the Earth’s ledger and those sorry stories of our failures as a species continue to reshape the planet.

Syrian toddler

[Syrian toddler – heartbreaking picture from last month’s news compelling our attention or detachment]

 

Postscript. It’s been a busy month academically and just last week I had the honor of being the Lloyd Visiting Professor in Portland, Oregon as a guest of Steve Skoog, John Barry, and Chris Amling. It is a great, storied department and excellent residents presented complex cases. I was mercifully given most of Friday morning off, allowing me to watch the televised visit of Pope Francis to the September 11 Memorial in NYC. The interfaith prayer service was remarkable with its rich array of colors and beliefs, connected by a shared overarching faith in mankind. The Pope’s presence and his comments offer inspiring counterbalance to the sobering image above and destruction memorialized at the Twin Towers sites. The multicultural colors assembled at that prayer service, symbolizing the rich potential of mitochondrial life and humankind, are the most impressive colors of this autumn.

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Thanks for reading What’s New, a posting from the University of Michigan Department of Urology, and Matula Thoughts, its blog version (matulathoughts.org). More on the department can also be found at: medicine.umich.edu/dept/urology.

David A. Bloom