Rules, boundaries, and stories

DAB What’s New June 1, 2018

Rules, boundaries, & stories

3722 words

 

One.

Colors explode as summer opens up in June around Ann Arbor. The visuals are unsurpassed in the UM Nichols Arboretum Peony Garden, adjacent to Mott Children’s Hospital. The garden is a few years short of a century old and derives from Dr. WE Upjohn’s flower collection (pictures above and below, May 29, 2018).

Schools let out in June and summer vacation begins for most students north of the equator, echoing our agrarian history when children needed to be free to work on family farms. Today, farms don’t depend on child labor and most schoolchildren come from urban/suburban homes, the rural: urban ratio having flipped in the last 150 years. In 1870, 25.7% of the US population (38.5 million) was urban and 74.3% was rural, while by 1990 the ratio was 75.2% urban and 24.8% rural (population 248.7 million) and the trend continues, although summer vacation still rules in most schools and workplaces. [Table 4 US Census Data 1993.]

Doctors in training don’t get summers off, they have full 12 month cycles of education, with one random month for vacation, and our new cohort begins its turn next month here in Ann Arbor. [Above: Grand Rounds.] Time has framed graduate medical education in urology since the formalization of the American Board of Urology in 1935. Urology trainees at Michigan spend five years of postgraduate training after medical school, shorter than my time of residency at UCLA, although residents today are increasingly likely to put in additional years for fellowship training. The idea of “duty hour” limitation was a reaction to a few bad training programs that exploited residents, and the 80-hour work week is the national standard for residents in training. Another quantitative constraint is the concept of minimum numbers of specific operative procedures.

A qualitative dimension of regulation, educational milestones, was implemented within the last decade. Milestones reflected the enticing idea that GME should not routinely progress only according to clock, calendar, and case numbers, but according to acquisition of skills. The increased burden of administrative time and paperwork to document milestones, however, has been unmatched by any demonstrable value for trainees or programs and, if common sense prevails, milestones will likely get swapped out for another idea or experiment. Nonetheless, it is clear that time and numbers alone should not be the only measures of residency education.

Our new GME cohort. Residents Kathryn Marchetti from UM, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Fellows Giulia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO).  New Faculty: Bryan Sack from Boston Children’s Hospital and Courtney Streur who completes her pediatric urology fellowship both join our Pediatric Urology Division. Kristin Chrouser has joined our faculty this year from the University of Minnesota in NPR and will be mainly at the VA.

 

Two.

Time, curiously, has no role in baseball, the game of summertime. The sport has no relation to a clock – rather milestones of innings, runs, and outs mark the game’s progress. In this, baseball lends itself to being the ideal summer sport, unfettered by time and limited only by accumulation of three failures or “outs” and innings unless bad weather intervenes or until it gets too dark to play.

Baseball at Night, a painting by Morris Kantor on display at the Smithsonian American Art Museum in Washington, DC, shows a minor-league game in West Nyack, NY, around 1934. Stadium lighting was a rarity then, given the long days of summer when play could continue until dark, although twilight made the game tenuous. Stadium lights shifted quickly from novelty to necessity and major league teams have played deliberate night games since 1935.

It’s hard to imagine baseball or any other sport without limits and rules, even if arbitrary or parochial, such as the designated hitter rule that now applies to one major league but not another. Rules matter and when different leagues play each other, they find it necessary to have rules that supervene their particular league rules. Rules create fair playing fields, allowing games to go forward and conclude peacefully.

Rules are equally essential for other social activities, organizations, and governments. The USA has the Constitution and Bill of Rights. The State of Michigan has its own constitution and laws, including term limits that guarantee frequent refreshment of the state legislature, but at the expense of deep institutional knowledge of the state and its components. The University of Michigan has its Regent’s Bylaws and Standard Practice Guide, as well as Michigan Medicine’s own sets of Bylaws. In all of these we rely on consensus for decisions, achieved casually in daily operations, more formally in committees (using Robert’s Rules of Order), and more broadly by public voting.

 

Three.

Communication skills are a pre-requisite for medical practice in both the essential transactions of direct patient care and in the complex team play of modern specialty medicine. [Above in foreground, Brent Williams, Professor of Internal Medicine, communicating with Michael Giacalone, Jr., Chief Medical Officer of the Hamilton Community Health Network in Flint.] Listening, speaking, reading, and writing skills are taught with variable degrees of success in elementary schools up through college, but medical practice demands more vocabulary and capabilities. Medical students, it is said, double the size of their vocabularies.

The traditional algorithm of healthcare starts with listening to the concerns of patients and then probing for additional information to construct a medical history, including relevant comorbidities and circumstances. Patients are physically examined and data is assembled into coherent narratives. Diagnosis, prognosis, and therapy derive from those stories in which authenticity and accuracy are assumed.

Modern electronic systems impose new communication challenges. Email and texting are immediate and convenient, but lack the human factors of facial cues, thoughtfulness, and social grace. Electronic medical records (EMRs) constrain work flows to templates and replace human narratives with check lists, pop-up choices, keyboard entries, and cut-and-paste phrases. The actions of data entry detract from listening, looking, and communicating with patients. Healthcare processes today do not prioritize stories, and it seems to me that appreciation of the art of the story lies at the heart of excellent clinical care. It’s no great leap of faith to claim that the art of authentic storytelling and story construction is the basis of most human relations, from compelling stories around campfires to A3 storytelling in lean process engineering. Truth and authenticity matter. Listening to them and weaving them are art forms.

 

Four.

Physician-author William Carlos Williams appeared on these pages earlier this spring and since then I’ve been thinking of the different contexts in which physicians write, and first and foremost, physicians write the stories of their patients.

Williams, you may recall, was the author of Spring and All of which a recent edition included an introduction by C. D. Wright comparing Williams to an earlier poet from New Jersey, Walt Whitman: “Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers.” [Spring and All. WC Williams. New Directions Book, 2011.]

We pursue that greater human understanding on a daily basis, working in medicine, through stories learned and experiences gained, patient-by-patient. The dilemmas of patients are understood in terms of their stories, that must be heard, elucidated, and constructed from evidence and reasoning on the part of those who undertake the responsibility for helping. Stories are important to people, and we dignify them with our attention.

Electronic medical records are poor platforms for authentic narratives. The construction of narratives in the minds of physicians and the translation to visible words in some medium is a core element of the profession of medicine, framing the response of the care-giver in terms of advice, reassurance, therapy, and prognosis. This is the central organizing feature of the doctor-patient relationship, comprising the daily shop-talk of medical practice. A story must be accurate, with true facts, but also authentic, in reflecting circumstances and co-morbidities (an economist might call these externalities) framing the “present illness” and creating a context for further conversation and therapy. In my experience, an authentic and empathetic story only fully emerges after the history, physical exam, and further discussion with patient and family.

My own clinic notes were once written or dictated well-after the clinical visit when the story was relatively complete and coherent. The reduction of clinical notes to formulaic elements such as the SOAP format (subjective, objective, assessment, and plan) or the E&M format (Evaluation & Management: chief complaint, history of present illness, review of systems, etc.) fits computer entry systems nicely, but has disrupted the traditional medical work-flow that create stories.

It is challenging to find the words to describe this fundamental type of medical writing whether in narratives or EHR. Quotidian medical communication seems to fit, even though not everyone is familiar with the use of quotidian for daily or routine. Quotidian communication must be accurate, truthful, and authentic to each patient. Most healthcare workers are writers and their products are stories of patients. A brief piece in The Lancet by Roger Kneebone called “The art of conversation” expresses the idea of the clinical conversation that we have clumsily called “taking a history.” Kneebone expressed his thoughts more elegantly than I have, so I’ll just quote two sentences and refer you to the rest. [The Lancet. 391:731, 2018.]
“A conversation is a one-off live performance that can never be repeated. Its essence is its evanescence, and attempts to capture in writing are as thin as reading the script of a play or film.”

 

Five.

Stories suffuse all types of medical writing. Scientific writing for journals, grants, or textbooks is the bedrock of healthcare research and progress. Just as with stories of patients, this writing is predicated on accuracy, and clarity is enhanced when a meaningful story is constructed from the science. Medical journalism, another form of medical writing, communicates to the public about medical science and practice. Medical memoir is another important genre, also written for the public but usually as personal storytelling or essays.

William Carlos Williams and others divert into creative reflections through prose and poetry. These writers mainly tell stories they create, often based on authentic experiences, but with “literary license.” Many of these physician-writers venture into fiction at the other end of the spectrum of medical writing, although this too requires authenticity in that stories revolve around individual experiences, conflicts, tensions, issues, and environments that are genuine to the reader’s senses. The fictions may involve other species or galaxies, as with the work of Michael Crichton, but if the stories are well-crafted they contribute to that greater authentic human understanding. To summarize medical writing variants: a.) the daily writing of clinical practice, b.) scientific writing, c.) medical journalism, d.) medical memoir, e.) creative reflections, and f.) fiction.

We are a species of stories and understand ourselves through stories far better than through data. That greater human understanding is accessed through narrative better than through numbers. The novelist Kazuo Ishiguro, in his 2017 Nobel Prize Lecture, praised the “… quiet private sparks of revelation …” to be found in stories. “Stories can entertain, sometimes teach or argue a point. But for me the essential thing is that they communicate feelings. That they appeal to what we share as human beings across our borders and divides.” [Ishiguro. My Twentieth Century Evening and Other Small Breakthroughs. AE Knopf. NY 2017.]

 

Six.

A pig story. It doesn’t take much to disturb a comfortable status quo or otherwise disrupt peaceful human relations. An obscure story exemplifying this began on June 15, 1859 on San Juan Island, a place east of Vancouver Island where both the United States and Great Britain claimed sovereignty, after the Oregon Treaty of June 15, 1846, exactly 13 years earlier. [Below: blue Haro Strait boundary favored by US, red Rosario Strait favored by Britain, green compromise proposal. Copyright Derek Hayes, Historical Atlas of the Pacific Northwest. Sasquatch Books, Seattle, 1999.]

Peaceful co-existence remained in play until a British pig, owned by Hudson’s Bay Company employee Charles Griffin, wandered onto an American farm to eat some potatoes. This wasn’t the first transgression and Lyman Cutlar, the American farmer, shot and killed the trespassing pig. Cutler’s offer of $10 compensation was refused and the British threatened to arrest him. Sixty-six American soldiers under the command of Captain George Pickett were dispatched to the island to prevent British forces from landing. The British countered, bringing three warships offshore, soon escalating to five ships, 70 guns, and 2140 men. American forces then swelled to 461 men with 14 cannons, as diplomacy failed and the dispute escalated into The Pig War. The British governor of Vancouver Island ordered Rear Admiral Robert Baynes to land his marines on San Juan Island, but Baynes wisely refused to further escalate the “squabble over a pig” and the war remained bloodless, aside from the porcine tragedy.

In October, President Buchanan sent General Winfield Scott to resolve the crisis and negotiations resulted in an agreement that the British could occupy the north half and the Americans the south with each side allowed up to 100 troops pending further formal agreement. No wall was built, and in 1872, a full 13 years after the ill-fated pig, an international commission led by Kaiser Wilhelm I, decided that the entire island should fall under American control and so it remains.

 

Seven.

Henry Martyn Robert was one of the 66 American soldiers stationed on San Juan Island under Pickett’s leadership. It’s hard to know how he felt about his mortal jeopardy over the cause of a pig, but it’s a good thing the conflict remained bloodless and Robert went on to bigger things. Born in Robertville, South Carolina, he grew up in Ohio where his family moved due to their opposition to slavery. Robert’s father, Reverend Joseph Thomas Robert, would later become the first president of Morehouse College (1871-1884). Henry went to West Point and graduated fourth in his class in 1857, becoming a military engineer and building the fortifications on San Juan Island in 1859. He remained with the North during the Civil War, attending to defenses around Washington, Philadelphia, and New England Harbors. After the war, he served the Army Division of the Pacific from 1867-1871, then developed ports in Wisconsin and Michigan, later improved harbors in New York and Philadelphia, constructed locks and dams in Tennessee, and performed more civil engineering pertaining to the Mississippi River and Hurricane Isaac in Galveston. He died in 1923 and is buried at Arlington. [Below: Brigadier General Henry Martyn Robert, Wikipedia.]

Although Robert’s military service was significant, we remember him today for his civil engineering of practical rules for human interaction. These came about in 1876 after losing control of a church meeting he was leading in New Bedford, Massachusetts when it erupted over abolitionist views. Robert blamed his ineptitude for the fiasco and decided to teach himself how to run a meeting. His study of the procedures of the House of Representatives led to his Pocket Manual of Rules of Order for Deliberative Assemblies. He wrote:
“One can scarcely have had much experience in deliberative meetings of Christians without realizing that the best of men, having wills of their own, are liable to attempt to carry out their own views without paying sufficient respect to the rights of their opponents.”

Robert’s world was framed by his gender and faith, but his rules have endured because they are independent of his particularities. Robert’s Rules of Order apply to almost any human gathering and, like the rules of baseball, Robert’s Rules level the playing field and allow the game to go forward. [“Historical Vignette 038 – An Army Engineer Brought Order to Church Meetings.” U.S. Army Corps of Engineers – Office of History. November 2001. Retrieved 2015-12-02.] His rules offer protocols for civilized and democratic behavior.

 

Eight.

Michigan hosted its first Teeter Symposium last month, focusing on bladder cancer in honor of our Ann Arbor friend Bob Teeter, who died a decade ago from bladder cancer in spite of radical cystectomy. [Above, Bob and Betsy Teeter; below, Teeter Laboratory Plaque.]

Since then, knowledge and therapy of bladder cancer have increased by a quantum leap, although more leaps are necessary to obliterate the pain, suffering, and mortality of that disease. The day-long event, organized by Alon Weizer, featured 2 guest speakers and held an attentive audience that topped 50, with excellent talks and superb discussions. The event fulfills one of the items on my bucket list as department chair and honored not just Bob and his surgeon Jim Montie, but also some generous gifts for laboratory investigation that we gained after Bob passed away.

The first guest lecturer, Thomas Bender, MD, PhD (above) from Dow Chemical, spoke about the Health Hazard Evaluation Program for former employees of a chemical plant that had been closed in 2002, but Dow later acquired its parent company, Morton, in 2009. As I sat in the audience, wondering how to link this month’s Matula Thoughts to the Teeter Symposium, Dr. Bender said a magic word: Paterson. That’s where the chemical plant had been since 1929. Paterson, New Jersey, was the home of William Carlos Williams.

The next invited speaker, Elizabeth Plimack MD, MS, Chief of Genitourinary Medical Oncology at Fox Chase Cancer Center, grew up in Ann Arbor. Her parents and mentor Richard Swartz were on hand to hear her excellent talk Immunotherapy and Beyond. In attendance was Monica Liebert (Nesbit 1984 below), now retired, but still working in our laboratories. Monica developed many bladder cancer cell lines in her heyday and these are still utilized in our research efforts.

Our own Khaled Hafez (below, Nesbit 2004) closed the event with a superb talk on Clinical Management of Patients with Locally Advanced Bladder Cancer, a topic close to his heart and emblematic of his skill set, as he is surely one of the best in the world at this craft.

 

Nine.

The AUA annual meeting last month in San Francisco featured the usual strong Michigan presence. San Francisco was also the site in 2010 where the picture of our inaugural chair, Jim Montie (Faculty Nesbit 1995), was taken. In addition to turning over a very strong group of faculty and department, in 2007 when the current departmental administration began, Jim turned over a positive team culture, rather than a “me-me-me” culture. Jim not only remained relevant to the department, but remains a keen participant and a role model of leadership.

 

Looking through those 2010 Nesbit reception pictures, I found a picture of the late and truly great Cornell Urology Chair, Darracott Vaughan, flanked by Jennifer Anger of UCLA and Hunter Wessells, chair at the University of Washington in Seattle (below).

But now back to 2018.

Above: Emilie Johnson, Nesbit 2011, with her iconic mentor from Boston, Alan Retik. Below: Julian Wan, Nesbit 1990, at one of his podium appearances, knocking it out of the park.

[Below: Music reception with Khurshid Ghani, Faculty Nesbit 2013, & David Miller, Nesbit 2005.]

The Nesbit reception this year at the Hotel Vitale on Mission Street hosted around 100 alumni, friends, and current team of the Urology Department. Below, a partial view of the crowd.

 

[Above: Damon Davis, Nesbit 2007. Brian Sack will start with us in pediatric urology this summer. Kristin Chrouser joined us this winter from Minneapolis and is centered at the VA. Below: Irene Crescenze current fellow FPMRS, Cheryl Lee, Nesbit 1997, now chair at Ohio State, Bert Chen, Nesbit 2006.]

[Above: Stu Wolf, Faculty Nesbit 1996, now in Austin, Udit Singhal PGY 2, Alon Weizer Faculty Nesbit 2005, Bunmi Olapade-Olaopa Nesbit, 2000. Below; Betty Newsom, Nesbit 1990, Bart and Amy Grossman, Nesbit 1977.

[Above: Lynda Ng, Nesbit 2005 and Jerilyn Latini, Faculty Nesbit 2003. Below: Steve & Faith Brown, friends of Michigan.]

[Above: Tom Stringer, Dept Urology Florida, Barry Kogan, Nesbit 1981 and Chair Albany. Below: Hugh Flood, Nesbit 1991, of Clonlara, County Clare, Ireland. Below: Simpa Salami, Nesbit 2017 & guest Mohamed Jalloh of Dakar, Senegal.]

 

Ten.

Boundary matters. A few months past the JAMA column, A Piece of My Mind, came from Jeffrey Milstein at Penn Medicine [Milstein. The envelope. JAMA. 319:23, 2018] and detailed his office visit with a 70-year-old patient who carried a large white envelope, assumed to be “outside records.” Most of us get these, not infrequently, indicating that a second or third opinion is expected. On the occasion of this particular visit, the details were those of a 32-year old son who had recently passed away due to cancer. The envelope contained a stack of records with an obituary on top. The patient first wanted to talk about his son and then the course of his disease, tests, hospitalizations, treatments, and emotional toll. Then, after “a long moment of silence” the patient explained that he himself had not been to a physician in years, but needed to tell his son’s story before committing to his own care. The clock had run down by then and “the time for the visit” was over leaving nothing that could be documented in the EHR about the patient himself. The author noted “so another visit must be scheduled.”

So, it seems medical care today has tight boundaries of time and information. Boundaries for nations, sports, politics, education, business, are important, but some are more important than others. The Pig War, a foolish dispute, easily could have escalated to bloodshed, leaving us no Robert’s Rules. Rules and boundaries in sports allow games to proceed fairly and end peacefully. Some boundaries in health care are tight and timeless, as evidenced in the Hippocratic Oath or as shamefully dishonored by occasional bad actors. The constraints of the EHR are self-inflicted wounds of the business of medicine, and should be viewed with minor contempt and never honored at the expense of a patient.

Baseball, timeless as it is, nonetheless must be somewhat mindful of the clock. Some fans may have babysitters, while transportation drivers and other workers are paid by the hour. The number of pitches thrown is a clock of a sort. Still, the essence of the game is indifferent to time. The same is true for conversations with patients. Life and schedules are much easier when each patient’s visit goes according to clockwork precision, but the essential transaction of the crucial conversations not infrequently runs afoul of anticipated timed encounters. These conversations are unique in the human repertoire and can have the most profound implications. Skilled clinicians know when and how to diplomatically crowd the later patients, run through lunch, or regroup with an expansive patient later in the day or soon thereafter. Such is the art of medicine.

 

Thanks for reading Matula Thoughts this June, 2018.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts October 7, 2016

DAB What’s New Oct 7, 2016

 

Education, errors, & box scores

3931 words

giants-vs-cardinals

One.               Autumn is academic medicine’s high season.  With summer officially over the serious work is well underway for faculty promotions, graduate medical education (GME) in academic centers, and continuing medical education in professional meetings. Residency interviews are beginning. Coincidentally, this is also the definitive season for baseball as major league teams compete for its World Series. [Above: San Francisco Giants 6 – St. Louis Cardinals 2. Sept 15, 2016. Cueto pitching.]

With participants notching up their games, rookie mistakes become occasional, although errors never totally go away.  Performance measurements allow individuals to understand and improve their work, while inviting inevitable comparisons. Fielders in baseball, for example, are judged by errors: the number of times they fail to complete plays that could have been made by common effort, a term roughly equivalent to the reasonable and standard practice by which physicians are judged.

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[Derek Jeter, Yankee shortstop. 8/24/08. Photographer Keith Allison]

It may seem awkward for physicians to talk of mistakes, however these conversations are not only necessary, but also healthy when done properly. We formalize these conversations in morbidity and mortality (M&M) conferences. Fortunately, most errors are minor if not trivial and are intrinsic to all biologic behaviors, indeed species variation itself is built on error. Health care cannot be expected to be exempt from error, for who among us has not missed a blood draw or an IV placement on first puncture? Who has not made a transcription error when typing an entry into today’s electronic medical record systems. (When I trained to become a surgeon, typing skills were not a required skill set; today many surgeons spend nearly as much time typing as operating – surely an epic waste of health care resources.) On the other hand, serious complications such as postoperative bleeding, deep venous thromboses, anastomotic leaks, or missed relevant comorbidities, bear inspections that should inspire personal and systemic improvements to minimize errors for future patients. While we take errors very seriously, we can’t let them disable us, for the next patient is always in line.

The point to make is that the conversation of error in health care is essential. The practice of medicine is, indeed, a practice and things that don’t turn out as intended need to be investigated to improve quality of practice. Charles Bosk’s 1979 book, Forgive and Remember, is a classic starting point. You can get a good summary of it in Robin Williamson’s review of its 2003 edition [J. Royal Society of Medicine. 2004 Mar; 97(3): 147-148]. While surgical fields have a long history of tough treatment of trainees, surgical training today (GME) is far less recriminating when errors are the result of earnest effort. [Below: Ed McGuire lecturing as emeritus professor to residents last year.]

mcguire-lecture

Two.           An astonishing array of events emblematic of our three-way mission initiated the 2016 academic high season of urology in Ann Arbor.

Inspiring Discovery was a celebration at North Campus Research Center focusing on partnerships with donors that fuel education and research. Tom Varbedian, distinguished Michigan alumnus, friend of our department, and retired ophthalmologist was among those honored, in his instance for support of medical students. He has funded 14 students over the years and 4 “Varbedian scholars” are presently here in medical school. [Below: Tom and some of his students]

varbedian-students

The evening was rich in meaningful stories of partnerships between donors and faculty to grow the conceptual basis and technology of health care while educating the next generation. Endowments are the key strength of Michigan’s future as a great academic medical center.

Dow Division Health Services Research Symposium targeted the topic of performance. The program by Jim Dupree, Khurshid Ghani, and Chad Ellimoottil featured our own and other world-wide experts who investigate and innovate health care delivery. This third biennial meeting included around 200 attendees.

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Jerry Weisbach Lectureship last month brought Martin Gleave from Vancouver, BC to discuss his extraordinary work co-targeting the androgen receptor and adaptive survival pathways in advanced prostate cancer.

Nesbit alumni weekend featured Freddie Hamdy from Oxford University describing his unique randomized trial of active monitoring, radical prostatectomy, and radiotherapy for localized prostate cancer. Two NEJM papers from his group last month attracted international attention and Freddie’s talk to us was the first public presentation. At the cutting edge of reproductive medicine, Sherman Silber explained how the Y-chromosome is becoming redundant in the light of the incredible accomplishment of creating sperm and ova from skin fibroblasts. Many other talks filled the program. We were honored to have senior urologists Cheng-Yang Chang, Clair Cox, and Mark McQuiggan in the audience. Cheryl Lee (Chair at OSU) and Stu Wolf (Associate Dean at Austin’s Dell SOM) were honored at our alumni dinner and John Park won the John Konnak award for service to our department. A lively Nesbit tailgate party preceded the Wisconsin football game.

hamdy

[Above: Freddie Hamdy presents results of prostate cancer trial. Below: Freddie Hamdy, Marschall Runge, Sherman Silber, Jim Monte & Nesbit attendees]

nesbit-group

After the Nesbit tailgate we saw Michigan edge Wisconsin out 14-7. Next year’s Nesbit alumni reunion will align with the Air Force Academy game here in Ann Arbor.

coxs-wisc-game

[Clair & Clarice Cox tailgating]

The Montie Visiting Professor was Ian Thompson, Jr.,  Director of the Cancer Therapy & Research Center of the University of Texas in San Antonio. Ian (below) spent childhood years (1956-59) in Ann Arbor when his father was on the Michigan urology faculty. A West Point graduate, Ian became Colonel in the U.S. Army and chair of urology at University of Texas San Antonio. He is President of the American Board of Urology. He spoke to us on the future of prostate cancer detection and therapy, and heard superb presentations from our residents and fellows.

montie-thompson

[Ian Thompson, Jim Montie]

This past month has been rich in education. Although these costly events interrupt the clinical work that supplies their main funding, they are educationally essential and important for quality improvement and team alignment. Quality of care is improved by expanding the conceptual basis of medical practice, clinical skills and professionalism of the workforce, and delivery systems. Alignment of healthcare workers is critical to their success in teams. In the face of new technology, new diseases, and a changing socio-economic-political environment these educational efforts cannot be sacrificed to clinical throughput.

Three.           The attendant at the gas station of life was a picturesque metaphor of Dr. Horace Davenport as he taught first year physiology to medical students here in Ann Arbor in the later 20th century (re-quoted by us in July What’s New and Matula Thoughts). The actuality of a physician’s role is more complex, as Dr. Davenport well knew, and the irony of his specific term attendant in the midst of an academic medical center full of attendings was probably intentional. (Another irony is that today’s gas stations, in contrast to those of Davenport’s time, are mostly self-service).

A physician is better understood from the neuroscience perspective with respect to mirror neurons. Humans are not unique in having these sophisticated forms of quorum sensors that facilitate empathy, a phenomenon seen in certain other biologic species such as crows, elephants, and of course fellow primates. Humans, however, have tools, skills, and systems that allow highly developed ways to operationalize empathy.

Physicians can no longer speak so territorially about their roles because health care is provided as significantly by nurses, physician assistants, and other advanced practice providers (APPs). The awkward term health care provider has crept into general use, and while downplaying the physician as a professional, the new terminology is necessary in the team play of modern healthcare. Regulatory and corporate forces reduce health care services to commodity encounters that match diagnostic codes to treatment codes. Many encounters can be delegated to APPs working at high ends of their scopes of practice. While vaccinations, dental cleaning, and sports physicals can readily be commoditized, whether routine “well patient” check ups or visits for uncharacterized problems can be similarly commoditized in 15 to 30-minute encounters remains to be seen. Some patients need the magic of attention and intuition from a health care professional that is not readily translated to check lists or passed down the ladder of expertise.

Effective attendants at life’s service stations hone their skills to observe and listen carefully while practicing their craft. In the process of listening and observing they need not only determine a patient’s diagnosis and an attendant treatment (ICD 10 and corresponding CPT codes), but also must discover relevant issues of the context of that person’s life in terms of livelihood, family, neighborhood, or socioeconomic condition. Context amplifies or minimizes any diagnosis and therapy. Without understanding the patient’s life story, that is the ultimate co-morbidities, an actual encounter in the office may have little value to the patient. All this is to say that effective attendants (physician, medical assistant, nurse, advanced practice provider, etc.) must seek to understand the patient as fully as possible, although such understanding is illusive and always incomplete.

Four.              Rabbit holes in time.   An article earlier this year in The Lancet by Kingshuk Pal, “Could you wait a second,” described a clinic visit with a woman in her mid-thirties. The encounter was allocated for a mere 10 minutes in his National Health Service (NHS) clinic in London, and in spite of an earlier add-on patient Pal was back on time for the last patient of the morning. He assumed the visit would be a simple encounter for a prescription, and indeed things started out that way. In fact, Pal had seen the same lady in brief encounters twice before and his colleagues had seen her other times as well to write prescriptions after going through standardized template checklists. However, Pal noted:

“But things didn’t feel quite right. I interrupted my internal monologue to go back over what she had just said … There was something about the vehemence with which she had expressed herself that jarred.”

Follow-up questions led into a “rabbit hole” that revealed an unexpected terrible social situation of an abusive marriage. Pal called in appropriate support services and eventually the lady became able to take control of her life. The missed opportunities to uncover the critical social comorbidity (spousal abuse) that was the basis of all of the previous encounters with the well-intended NHS physicians surely would be considered errors in other occupations. Pal commented on earlier missed opportunities to rescue the patient:

“… each time we had stuck to our templates. We were focused on her medical needs. We had listened to what she said, but not what she meant. What had been left unsaid was how much she needed kindness, sympathy, and patience. For me to give her a few seconds of my silence so that she could finally break hers. I know if I had been busy, it would have seemed like that would take forever. But the passage of time is a peculiar thing. As strange as in a consultation as it is in Wonderland:

Alice: ‘How long is forever?’

White Rabbit: ‘Sometimes, just one second.” [The Lancet. 387:1900-1901, 2016]

Five.               Attending at the station. John Berger’s factual description of a rural English general practitioner in the 1960s is an understated gem of medical literature. Berger and photographer Jean Mohr spent six weeks with the doctor. More than shadowing him, they embedded in his practice, living with him and his wife in St. Briavels in the Forest of Dean, Gloucestershire. The physician, John Eskell, was named John Sassall for the book, A Fortunate Man: The Story of a Country Doctor, although accounts of patients and the community were otherwise factual. Berger and Mohr observed Eskell/Sassall in his clinic (called the surgery) and dispensary, as well as on his house calls.

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This somber book has underlying themes of optimism in human kindness, meaning, and extraordinary curiosity that some people, such as Eskell possess. Berger explains how the morbidity and comorbidities of patients became the personal burden of Eskell.

“I said that the price which Sassall pays for the achievement of his somewhat special position is that he has to face more nakedly than many other doctors the suffering of his patients and the sense of his own inadequacy. I want now to examine his sense of inadequacy.

There are occasions when any doctor may feel helpless: faced with a tragic incurable disease; faced with obstinacy and prejudice maintaining the very condition which has created the illness or unhappiness; faced with certain housing conditions; faced with poverty.

On most occasions Sassall is better placed than the average. He cannot cure the incurable. But because of his comparative intimacy with patients, and because the relations of a patient are also likely to be his patients, he is well-placed to challenge family obstinacy and prejudice. Likewise, because of the hegemony he enjoys within his district, his views tend to carry weight with housing committees, national assistance officers, etc. He can intercede for his patients on both a personal and bureaucratic level.”

Six.                 Personalized medicine. Comorbidities unquestionably impact illness, and without understanding them in at least some depth, physicians can hardly claim to deal out meaningful advice and therapy. Today we confuse recognition of comorbidities, by our ability to list billing codes, with actual understanding of comorbidity relevance and impact. Prominent in Sassall’s example is the matter of who he is outside the clinic and dispensary. He represents something positive in the community and accordingly he is not quite free to live a life that doesn’t impact favorably on him, his environment, or his profession. He accepted that “trade-off” when he accepted his role as a physician. Berger continues his explanation.

“He is probably more aware of making mistakes in diagnosis and treatment than most doctors. This is not because he makes more mistakes, but because he counts as mistakes what many doctors would – perhaps justifiably – call unfortunate complications. However, to balance such self-criticism he has the satisfaction of his reputation which brings him ‘difficult’ cases from far outside his own area. He suffers the doubts and enjoys the reputation of a professional idealist.

Yet his sense of inadequacy does not arise from this – although it may sometimes be prompted by an exaggerated sense of failure concerning a particular case. His sense of inadequacy is larger than the professional.

Do his patients deserve the lives they lead, or do they deserve better? Are they what they could be or are they suffering continual diminution? Do they ever have the opportunity to develop the potentialities which he has observed in them at certain moments? Are there not some who secretly wish to live in a sense that is impossible given the conditions of their actual lives? And facing this impossibility do they not then secretly wish to die?”  [Berger. A Fortunate Man. 1967. Vintage International Edition 1997. p. 132-133.]

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[Jean Mohr photo p. 50]

The doctor confronts existential issues in these questions. Berger makes the case that Sassall’s biggest inadequacy was an inability to counter the comorbidities that framed the immediate morbidities of his patients. Sassall was an idealist who tried to fix morbidities and co-morbidities patient by patient. His intermittent successes fueled his perseverance.

Seven.           Mistakes. Medical practice in Eskell’s day was mainly the binary proposition of doctor and patient, family “comorbidity” notwithstanding. Physicians had far fewer tools at their disposal than today’s incredible armamentarium, but it requires teams to deploy modern healthcare’s tools. No single John Eskell can deliver today’s miracles, although confoundingly the complex paradigm of multidisciplinary team medicine greatly increases the opportunities for error. The complexity of healthcare today and the multiplicity of people involved in the teams delivering it, has magnified the chance for mistakes in the intervening half century.

The Journal of the American Medical Association recently introduced a new department, JAMA Professionalism, with an inaugural article on disclosure of medical error. The case summary described a dermatologist who had just performed skin biopsies on two patients only to discover that the instruments he had just used had not been sterilized. The ensuing discussion revolved around the issues of disclosure and analysis of the error to preclude its repetition. [W. Levinson, J. Yeung, S. Ginsburg. Disclosure of medical error. JAMA 316(7):764-765, 2016]

A phrase has stuck with me from John Shook, the insightful “zen-master” of lean processes: I can’t remember exactly where or when he said it, but it goes like this: for us to fulfill our role, we have to keep on learning. screen-shot-2016-09-11-at-8-17-58-pm

[John Shook on right with Jack Billi]

Eight.             Retrograde thoughts. Everyone brings a unique identity to their work, and in health care the idiosyncrasies of each practitioner resonate with particular specificity in the nature of his or her practice. The professional motivations, world-view, aspirations, distractions, personal demons, work-ethic, curiosity, consistency, empathy, attention to detail, ability to listen and observe, as well as commitment to community are unique to each practitioner and are manifested distinctly in each practice, and with each patient. A mandate for professionalism is intended to bind all these variables together in the practice of medicine, but this is necessarily a vague aspiration although a national trend seeks to define a professional standard and perhaps reduce it to metrics and benchmarks. A national set of professionalism standards or a GME curricular competency can never replace the role models of John Sassall/Eskell and so many others.

It may be subversive to suggest, in today’s world of measurement and precision in medicine, that if you can’t measure something of importance, you still can (and must) improve it. The discovery of what matters to a patient may not be readily measureable. On the other hand, for things that are measureable a certain degree of precision does not matter. Whether you weigh 170 pounds vs. 169.573 pounds, or whether your creatinine is 1.2 or 1.18746, or if your BP is 120/80 or 117.3/78.4 the precision is irrelevant. However, if your abdominal aortic aneurysm or renal transplant are managed by medications that you are reluctant to admit you can’t afford – that fact really matters.

Nine.              A growing body of literature punctures any remaining illusions of the perfection of medical practice. Atul Gawande’s Complications and Henry Marsh’s Do No Harm are good examples of this genre of story-telling and introspection. This type of work is instructive, although limited to single examples of individuals, sometimes approaching the point of titillation or voyeurism. Anecdotes certainly have value, acting like fables that accrue in our minds and bring us to greater wisdom in future actions. Lacking any real-time peer review and team-based process improvement, however, these personal denouements and anecdotes are unlikely to achieve larger scale in medical practice quality improvement.

Autopsy of errors or failures is more purposeful in driving deliberate changes in the ways we deploy work, whether in the structure of a clinic visit or the steps in an operative procedure. This turns out to be the very holistic idea of the Toyota Process Systems that has translated in western business as lean engineering. Reconsidering that pseudo-scientific phrase, if you can’t measure it you can’t understand or fix it – this adage is useful, but should not become dogma. Of course, measurement is essential to understanding and improving things, but measurement is not central to all sophisticated human processes. Ideas are central to understanding and progress, and measurement is only a tool used along the way to test hypotheses, measure performances, or test results.

henry_chadwick_baseball

Henry Chadwick (1824-1908) initiated the practice of recording statistics based on his experience in the game of cricket. He applied these methods to baseball after discovering the game in 1856 while “cricket reporter” for the New York Times. His box score for reporting the game, adapted from the cricket box score, has blossomed into contemporary baseball statistics of batting average, runs scored, base on balls, strike outs, runs batted in, earned run average, fielding percentage, and errors, to name a few before falling into the more complex Sabermetrics. Numbers can replicate or model a game, but they cannot substitute for the performance of the game itself.

1876boxscore

[1876 Box score: Wikipedia]

 

 

Ten.               Boston surgeon Ernest Amory Codman (1869-1940) was an intellectual successor to Chadwick in the realm of health care, where scoring is more complex than in baseball. [Below: Codman collecting data.]

codman

Eskell and Codman were obsessively committed to their work, but centered on the patient in different ways. Both men were mavericks. Codman focused on measureable outcome, he called this the end result idea, and believed that individual physicians and hospital record systems should keep relevant information. Eskell attended to the patient in the moment and in the environment. Each physician was overwhelmed by his own idea. Codman became alienated from his colleagues and went bankrupt self-publishing his book on the end-result idea, A Study in Hospital Efficiency.  Eskell focused on his immediate performance delivering health care one patient at a time, attentive to their inevitable comorbidities, but he ultimately committed suicide. Whether their unfortunate ends were due to highly sensitive mirror neurons overwhelmed by the woes of the world, or obsessive personalities that closed the door to sufficient joy to offset their burdens is a mystery.

The word detachment caught my attention when I finished surgical residency at UCLA. My inspirational chief was William P. Longmire, Jr. and, just as our completing residents and fellows and the Nesbit Society, I was given a diploma when I finished training. The Longmire Society logo was a symbol with four corners that read: Detachment, Method, Thoroughness, and Humility. At the time (it was 1977) I understood three of the attributes, but found detachment somewhat odd: why include that word?

Over the years. I’ve come to understand it better. Clearly, Codman and Eskell suffered from inadequate detachment. Dr. Longmire, a great surgeon, found the right balance. He knew his patients quite well, but had the necessary detachment to make a grand incision, put his hands in the abdomen, and fix most any problem with exquisite skill and judgment. He felt the need to warn young trainees to develop similar detachment.

The world is different today. Minimally invasive surgery, OR checklists, and electronic health records serve their purposes, but distance us from patients. Indeed, with robots a surgeon never needs to physically touch a patient, surrogates and checklists can stand in the way. Don’t get me wrong, I have benefitted from the robot and I believe in systems (although not obsessively). However, when it is not the surgeon’s hand that makes the incision and it’s not the surgeon’s hands in the body, the doctor-patient relationship is changed, even if in a subtle way. This is reminiscent of the old farmer’s adage: if you have ham and eggs for breakfast, the chicken was involved, but the pig was committed. The new tools, the regulations, scorekeeping, and the economics of health care have created an environment of significant detachment for our trainees. We no longer need to warn them to develop that sense, rather we need to inspire the right extent of involvement and commitment that will lead them into rabbit holes and other avenues of inquiry as caring attendants at the gas stations of life.

Health care performance is now judged by a multitude of variables, some worthy and others less so: patient outcomes may not be evident for years, peer review at M & M conferences drives quality improvement, and performance measures du jour, such as Press Ganey data, remind us of our public responsibility. Ultimately, our game has no final box score. The practice of medicine is an individual art, evolving as knowledge and technology accrue and as self-knowledge notches up, one hopes in lockstep with experience, patient by patient, whether in the springtime or autumn of our careers. Measurements can improve elements of our performances, but will never substitute for artful performance itself.

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[Michigan 14 – Wisconsin 7,  Nesbit Weekend 2016]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor