December

Posted by dabloom

Matula Thoughts Dec 7, 2018

3930 words

One.

Tiny Tim Cratchit and Ebenezer Scrooge come to mind in December when seasonal good cheer expands the possibilities of latent human kindness, turning some Scrooges into their better selves, exemplified by Charles Dickens’ 1843 tale. The author played the story well, for who can’t empathize with Tiny Tim, whose disability reminds us of the Americans with Disabilities Act (ADA), signed by GHW Bush in 1990? The late president said, at the signing, that he was glad to help take down “that shameful wall of exclusion,” little knowing that the ADA would help his own access to public spaces during his wheelchair years 25 years later. [Above, upper Liberty Street, cold afternoon. Below: Tiny Tim & Bob Cratchit. Fred Barnard illustration for 1870 ed.]

We don’t need Marley’s ghost, to exercise our philanthropic nature this month. [Above: Scrooge enlightened by Marley’s ghost. John Leech Illustration in A Christmas Carol, Chapman & Hall, London. 1843. British Library.] Tax advantages, to a dwindling extent, also enter the philanthropic calculus as people evaluate well-constructed requests for their dollars. Pleas for out-of-pocket “spare change” from panhandlers is a complex matter, sometimes linked to homelessness, but just as likely separate and multifactorial. Like most human enterprises, it grows if supported. Solicitations on the streets are often more a business rather than a solution to hunger, homelessness, poverty, mental illness, or substance abuse. Panhandling makes downtown spaces a little uncomfortable, and although handing over a buck provides momentary satisfaction, it doesn’t further the greater good of the truly needy or the public.

The community of Ann Arbor has come together for excellent programs such as the Delonis Center, Ozone House, Alpha House, Salvation Army Shelter, Dawn Farms, Home of New Vision, Packard Clinic, Hope Clinic, and Neutral Zone, but these don’t fill all the needs of homeless or otherwise at-risk people. Spare change gifting has a doubly negative effect: it encourages the business of panhandling, and it relieves guilt of panhandled individuals, who preferably could expend constructive efforts on durable solutions to the causes and needs of the people who seek help. Shelters, food banks, health care, public safety, job programs, education, and low-income housing, need political support, public policy solutions, volunteerism, and philanthropy. If you encounter a panhandler and feel guilty, consider pointing out a nearby shelter or offering a nutrition bar. [Below: Sidney Paget illustration, The Man with the Twisted Lip. Arthur Conan Doyle, 1981.]

Two.

Galens Medical Society, founded in Ann Arbor in 1914 as a liaison between students and faculty, began charitable Tag Days in 1927 and solicits funds on the streets the first weekend in December. Medical school became costly in the 20th century and in the 1930s Galens established scholarships and a loan fund. Galens now targets its funds to children’s needs in Washtenaw County.

Salvation Army kettles usually decorate December streets, although I saw few this past weekend. This evangelical church began in 1865, when Methodist circuit-preacher William Booth and his wife sermonized at the notorious Blind Beggar tavern in East London. The Salvation Army is best known for its crusade against alcoholism, as portrayed in George Bernard Shaw’s 1907 play, Major Barbara. The organization uses military titles, the CEO is referred to as General, and the kettles began in 1891 when Salvation Army Captain Joseph McFee placed one at San Francisco’s Market Street Ferry Landing to collect Christmas dinner money for impoverished members of the community. Disaster relief is another function of the organization.

Homelessness also applies to pets, and the Huron Valley Humane Society is another consideration for your generosity. Philanthropy, or anthrophilia, is a restricted form of biophilia, a term embraced by E.O. Wilson, who wrote:

“… to explore and affiliate with life is a deep and complicated process in mental development. To an extent still undervalued in philosophy and religion, our existence depends upon this propensity, our spirit is woven from it, hope rises on its current.

There is more. Modern biology has produced a genuinely new way of looking at the world that is incidentally congenial to the inner direction of biophilia. In other words, instinct is in this rare instance aligned with reason. The conclusion I draw is optimistic: to the degree that we come to understand other organisms, we will place a greater value on them, and on ourselves.” [Wilson EO. Biophilia. Harvard University Press, 1984. p. 1-2.]

Three.

The urology chair will transition next year as the Michigan Urology Centennial approaches, and the first part of the Michigan Urology story should be in print at next year’s Nesbit Society meeting, October 3-5, 2019. The early history of UM reveals the foundational role of philanthropy, beginning as a partnership of community, state, and generous people who wanted to create something worthy and great in Ann Arbor. The same was true for its first hospital. With declining support from local and state government, philanthropy becomes mission-critical, evidenced by the recent University of Michigan campaign with $1.5 billion dollars for Michigan Medicine, celebrated last month at the North Campus Research Center. [Below: Becky and Randy Tisch flanked by Harry and Natalie Mobley.]

Endowments and endowed professorships impact our department greatly. The Babcock Fund jump started dozens of research projects and bolstered our residency and fellowships for 80 years. The Lapides endowment affected my career, Stuart Wolf’s small renal mass data set changed the worldwide approach to kidney cancer with the Brain and Mary Campbell family gift, and the professorship from George Valassis very positively helped the careers and academic work of Jim Montie, Dave Wood, Ganesh Palapattu, and Khaled Hafez. The Brandon survivorship gifts have been of inestimable value to hundreds of patients and the career of Professor Daniela Wittmann. The Chang, Nesbit, McGuire, and Moyad professorships followed, as did the Complementary/Alternative Medicine Program under Mark Moyad, initiated by Phil Jenkins, Bob Thompson, and Josh Pokempner. We are still short by ten of the need to match professorships to the expanding ranks of senior faculty. Endowed professorships will be the essential structural elements for any great clinical department of the future.

Jerry May, UM Vice President of Development, steps down after 30 years of bountiful leadership (above, during a tough day in Columbus). Eric Barritt (below with John Copeland) has effectively led Michigan Medicine development for four years and we have enjoyed Vince Cavataio as urology’s development officer over the past two years. Endowment-building requires diligent work with a good measure of luck. In this sense, it is both stoichiometric (assembly with the right elements and proportions) and stochastic (random).

[Below: at Nesbit tailgate Vince and Tonya McCoy.]

Four.

Moral dilemmas of health care were explored in another Shaw play, The Doctor’s Dilemma, first produced November 20, 1906. Its Preface provides an even sharper dissection of the medical profession than the play itself. Parsing of scarce medical resources was exemplified in the story by a new cure for tuberculosis (TB) that its physician-inventor, Sir Colenso Ridgeon, could only provide to ten patients at a time. From his first group of 50 TB patients Ridgeon had to select ten “most worthy” of cure. Personal foibles added to the doctor’s dilemma when an irresistable young woman asks him to cure her dissolute husband. Around the same time a poor but noble colleague of Ridgeon’s with TB also appeals for help. Suddenly, Sir Colenso has 52 patients in need, but still only resources for ten. His other dilemma was the timeless conflict between medicine as a profession and a personal business.

Shaw modeled Ridgeon on Sir Almroth Wright (1861-1947), British bacteriologist and immunologist (below) who was one of the first to predict that antibiotics would create resistant bacteria, an idea Shaw used in his 1932 comedy, Too Good to Be True. Wright was opposed to women’s suffrage and their entry into professions, writing a book in 1913, The Unexpurgated Case Against Women Suffrage. Wright’s contrary nature probably made him suitable for Shavian friendship and earned him the names “Almroth Wrong” and “Sir Almost Right.” Wright would have raised his eyebrows had he visited Ann Arbor when the Galens Society began and found women included in the Michigan medical school class since 1871.

An essay by Michael O’Donnell in the British Medical Journal, might inspire you delve further into Shaw’s play and its Preface. O’Donnell recently adapted the play “as if for radio” and had performers read their parts, on the 100th anniversary of The Doctor’s Dilemma. O’Donnell’s essay concluded with a barb directed toward the banal teaching of “communication skills” rather than venturing into the “richer territory explored by dramatists”:

“If doctors are to treat illness as successfully as they treat disease they have to enhance their medical experience with some understanding of the world in which they and their patients struggle to survive. Their need, I suggest, is not ‘communication’ but the empathy and understanding that, thanks to Shaw, we and our audience shared on that memorable evening. And we never knowingly deployed a key communication skill.” [BMJ. 333:1338-1340.]

The years immediately following Galens origin and Shaw’s heyday severely tested Ann Arbor and the world beyond. The First World War, a catastrophe for millions, rearranged global geopolitics. The influenza epidemic, known as the Spanish Flu, infected one third of the world population with one in ten (50 million) dying from it. Spain can’t be blamed, for the disease didn’t originate there. As a neutral party in WWI Spain freely reported news of flu activity while other nations restricted information to maintain public morale and to mask information about troop illness. The War spread the flu through close quarters, troop movement, and hygiene disruption. The first U.S. flu wave commenced in the spring of 1918 in military camps and cities. A second wave emerged that September at U.S. Army Training Camp Devens outside Boston. A third and final wave in 1919 ran through the spring. When President Wilson collapsed at the Peace Talks in Versailles, Paris was still in the throes of the flu, and it has been speculated that Wilson was suffering from it. The flu was gone by summer, but H1N1 virus persists.

Five.

December 7, 1941, jolted Ann Arbor, like the rest of the country, with the Pearl Harbor attack. Wayne Dertien of Hudsonville shows the December 8, 1941 edition of the Grand Rapids Press, the day after Pearl Harbor (above). This picture (online from 12 June 2013 MLive.com) demonstrates how people saved newspapers or magazines to memorialize a milestone event and, presumably, return to it from time to time. How this will happen now that Gutenberg has gone digital is anyone’s guess, although it should be noted that the convenience of the internet brought me to Mr. Dertien’s picture. We located Wayne and spoke to him recently to get permission to repeat his picture and story, and he commented on how he found the article in a basket his late mother had kept with other articles and magazines that she valued, including an article on the Kennedy assassination.

For urological reasons, 1941 was also noteworthy: a paper that year by Charles Huggins, one of Michigan’s first two urology trainees, led to his Nobel Prize in Medicine in 1966. The other original trainee, Reed Nesbit the first titular head of urology at Michigan, was extraordinary in his own right, as a formative figure in urology practice, education, and research.

In 1941 Nesbit brought two young men to Ann Arbor for residency in his 13th class of residents: Dolphus Compere and Robert Plumb. (Nesbit would eventually have 36 “classes” of trainees.) I got to know Dolph through the tireless work of Maureen Perdomo, one of our development officers in the earlier years of my term as chair. Maureen was totally devoted to our urology alumni and had tracked down Dolph to a retirement home in Fort Worth. Dolph Compere (1916 – 2012) was raised by his mother in Texas after his father, a physician, died of injuries suffered in WWI. Dolph graduated from the University of Texas in 1937 and got an MD from Baylor in 1941. He came to Reed Nesbit and UM for residency in the summer of 1941 and returned to Texas to get married during his December vacation. WWII had broken out just days before the wedding. Returning to Ann Arbor Dolph asked Nesbit for permission to enlist, but Nesbit said he “wasn’t ready.” In 1943 Nesbit released him for duty. We have Dolph’s story of his time in the Pacific Theater and will include it in the Michigan Urology story. Dolph’s co-resident, Bob Plumb, is another story we are pursuing. [Below: Dolph Compere welcoming me and David Miller to Dallas in 2010.]

Six.

Events that conspired to cause the two world wars of the past century centered around national misunderstandings among governments that had been high-jacked by extreme points of view. Great efforts were made after WWI to minimize the chance of another great war by promoting international cooperation. Going through papers of University of Michigan president Hutchins at the Bentley Library, I found documents asking him to support a League of Nations, that was established January 10, 1920, and resulted in a Nobel Prize for Woodrow Wilson. The United States never joined and, whether related to that fact or not, a second World War broke out twenty years after ‘the war to end all wars” had ended and the League was dissolved in 1946. With these thoughts in mind, it should give us pause that international cooperation has given way to the deal of the moment. This may reflect a post-truth attitude in human society where are facts are relative or utilitarian, without shared belief in objective truths that transcend nations and disciplines. We see this in politics, in the news industry, and in entertainment. This attitude is infecting journalism, academia, science, and medicine.

Urology makes the world small because of collegial friendships, belief in inquiry, and collaborations connecting us around the world in spite of oceans, borders, walls, or professional turfs. I took this picture a year ago on the Great Wall (above), after a meeting at the home base of one of the most innovative pediatric surgeons and urologists of our time, C.K. Yeung (below).

Whatever the Great Wall divided or protected is long gone. Our guide said it may be the largest cemetery of our species, as fallen workers were buried in or alongside it as they died.

Intellectual walls are equally puzzling. One example is the deep resistance to Lister’s solid evidence for the effectiveness of antisepsis, presented so clearly in The Lancet in 1867. Resistance to that compelling evidence was plainly obtuse. Many iconic leaders of the time were defiant, notably Samuel David Gross, claimed by many at the time to be “The Father of American Surgery,” and immortalized by Eakins with a bloody bare hand during surgery in The Gross Clinic (1875). The year following the painting Gross wrote: “Little if any faith is placed by an enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister.”

An educated mind is literate in science as well as the humanistic thought of past millennia. You can’t have one form of literacy without the other to develop the critical thought necessary to understand the important issues of our time. Many are existential concerns, if not for us, then for those who follow us. [Below: paradigm shifts, Hong Kong Harbor, December, 2017.]

When paradigms shift, as they always and inevitably do, walls don’t serve us well.

Seven.

Charles Dickens dealt with many existential concerns of his time, poverty, environmental deterioration, ignorance, crime, violence, malnutrition, and health disparities. These continue today. Born February 7, 1812 in Portsmouth, England, Dickens lived only 58 years, dying after a stroke in 1870. Most notably for my profession, pediatric urology, he was a supporter and philanthropic fundraiser for the fledgling hospital, Great Ormond Street (GOS), where modern pediatric urology began a century later with the work of Sir David Innes Williams (below, flyer for Dickens reading to benefit GOS). Imaginative literature produces colorful language for the medical profession.

Writing under the pseudonym Boz, in 1836, Dickens contributed to a publication called The Posthumous Papers of the Pickwick Club, eventually taking over the monthly periodical. The serialized story became Dickens’s first novel, The Pickwick Papers, and centered on the fictional Samuel Pickwick, Esquire, founder and perpetual president of the club. Kind, wealthy, and rotund, Samuel Pickwick’s phenotype informed a medical condition that came to light more than a century later, in the 1950s. Other figures in the Pickwick Papers included Nathaniel Winkle, Augustus Snodgrass, Sam Weller, and Alfred Jingle. Coincidentally two friends of mine in urology share surnames of those club members.

[The Pickwick Club. Charles Dickens 1838. NYPL Berg Collection.]

Pickwickian syndrome is the obesity hypoventilation condition in which some people, severely overweight, fail to breathe enough to maintain sufficient oxygen levels or low enough CO2 levels, causing sleep apnea. A BMI over 30 kg/m2, hypoxemia, and hypercapnia define the condition. [Kryger M. J. Clin Sleep Med. 8:333-338, 2012.] Other Dickensian conditions include Tiny Tim’s ailment requiring a crutch, perhaps due to Pott’s disease or renal tubular acidosis, and Major Bagstock who exemplified bronchoconstriction & cyanosis. Our own faculty colleague, Howard Markel, did a nice piece on the Public Broadcasting System (PBS, Feb 6, 2016) entitled Was Dickens the first celebrity medical spokesman?

Eight.

An essential, existential, meme. The philanthropic idea of Adam Smith was his first big idea. Philanthropy, a generalized warmth toward fellow creatures, extends beyond kith and kin. It is literally “a love of mankind.” This is the foundational condition behind education, health care, and the government of liberal democracy. Freedoms including journalism (“the press”), speech, religion, assembly, lobby, and personal enterprise within the constraints of law, derive from this intrinsic human characteristic of philanthropy.

At the end of a good run, I don’t want to hyperpersonalize my term as our department’s second chair and 9th urology chief, from Cabot to Montie, I was only as effective as the people around me: our staff, faculty, nurses, PAs, and residents are wonderful. I heard a recent interview on NPR that included an alleged quote from the film director Orson Wells, who said something to the effect that the role of a director was “to preside over accidents.” Whether I can trace this quote back to its origin and find it to be a true fact or not, is less important than the thought itself that any director, chair, administrator, or team leader is at the mercy of the randomness of the actions, performances, beliefs, or events that surround the stakeholders and bystanders of the enterprise.

Stochastic events are central to all parts of biology, whether genomic function, epigenetic determination, molecular assembly, behavior of any self, or teams. Life is attended by stochastic randomness, events and processes that may be explained by probability distribution, but are not precisely predictable. In this sense they are, perhaps, accidental or random. These events and processes may be mathematical, chemical, epigenetic, or social like an Orson Wells play or the management of an academic urology department. Ideas and memes, possibly the most complex biologic products, are also stochastic, as they arise. They may be good or bad, useful or destructive, true or false. We may think our dreams and ideas are accidental, stochastic as they seem to appear randomly, although they are not quite random – they have sources, coming from some conditions, memories, anxieties, wishes, or other places in the mind.

The idea of stoichiometry, so close in sound, is something quite different, intending a precision based on the chemical idea of conservation of mass. A film director or a leader of an academic clinical department needs people, props, and data. For the director, a film has a budget, it needs equipment, sites, actors, support teams (including those “best boys”), props, food, payroll systems, and a distribution plan. These are the necessary components of motion pictures. The many performances that comprise the final product, however, cannot be determined by numbers, data, or stoichiometry. Although performances may be studied, rehearsed, and coached, they are ultimately accidental. A director must provide milieu, and perhaps inspiration, but if good actors are on the scene, a good director might be most effective by getting out of the way of the characters and their art. A producer may go to an accountant to help manage the accounts, but not to direct a film. Academic units are not greatly different.

Nine.

Philanthropy is fundamental to humanity at the level of family and tribe, it is built into our DNA as it is in other primates and many other mammals. The love and philanthropy that we give to family and neighbors preserves and grows society, in that it is a specific and necessary component of the human condition. It is part of the stoichiometry of our species, it is a proportionate part of the mix, albeit expressed variably from person to person. It is at the heart of the early religions and cultures that defined humanity and in many cases tried to extend the idea beyond any specific family, culture, nation, or religion. Philanthropy is stoichiometric in that it is a specific and essential part of the mix of our species, but it is also stochastic or random, in the binary sense that it can happen or not happen.

Philanthropy in this sense, as a meme, had its most insightful articulation by Adam Smith, in the first sentence of his first book, The Theory of Moral Sentiments, when he wrote in 1759:

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

As a meme, this particular thought of Smith’s was not totally random in that it was shaped by millennia of human thought, his personal upbringing and education, and the society surrounding him (the astonishing Scottish Enlightenment). But as a thought that inspired his book, it popped up in his brain and was shaped into a very compelling and durable meme – the generalization of philanthropy to all of humanity. While this aspiration had been set out in the great human religions long before Smith, his meme was not compelled by a deity or demanded by a social code.

Smith recognized that each person has some nugget of generalized philanthropy within. In this complex world of 7 billion people, interwoven with perhaps only a few “degrees of separation” from each other, the meme of Adam Smith, generalized philanthropy and its first cousin, global human cooperation, is more than just a meme, it is now an existential necessity. Our genes compelled familial and tribal philanthropy that have carried us this far to human domination of the planet through the powerful tools of education, science, and technology. However, we can’t go much further without full deployment of the memes of philanthropy and global human cooperation.

Ten.

Leadership change is around the corner for our department and it comes at a fortuitous time with the Michigan Urology Centennial about to start later next year. This will signal a change in the weekly What’s New email communication of the Department of Urology, as that communication format and paradigm should be a choice of the next administration. On the other hand, the web-based monthly version, Matula Thoughts, will continue as best it can by this writer at the web site matulathoughts.org. The quirky title derives from the uroscopy flask that identified the entire medical profession for many centuries. Laennec’s invention of the stethoscope in 1816, supplanted the matula and is a far better symbol for the medical profession, epitomizing the idea of listening. Furthermore, the stethoscope is far more portable and durable than glass flasks, and contains little in the way of biohazard, except for an occasional bit of wax.

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

Transitions.

Posted by dabloom

DAB What’s New Dec 1, 2017

3818 words

One.

The Michigan Theater, seen above on a crisp autumn evening, is one of Ann Arbor’s many delights, making it easy to “sell” our town to medical students who interview for urology residency. Reflecting the halcyon days of motion picture palaces, the theater opened January 5, 1928 with grand lobbies, 1700 seats, a Barton theater organ, and an orchestra pit. Now, after ninety years of capital campaigns and restorations, the building has three auditoriums and is the center of the Michigan Theater Foundation, a world-class non-profit center for fine film and other cultural events. Its State Theatre, across the street, reopens this month after a well-earned renovation. Michigan Theater hosts the Ann Arbor Symphony Orchestra, Cinetopia International Film Festival (in partnership with the Detroit Institute of Arts), organ concerts, and other live-stage events. When days in the next few months get gray, slushy, and cold, the Michigan Theater is a wonderful refuge and it’s equally delightful the rest of the year.

“I’ve seen this movie before” is a phrase in vogue for recurrent phenomena and so it seems with the autumn ritual of residency applications. Fourth-year medical students travel around the country as “sub-interns” to audition at training programs in hopes of securing 5 to 6-year residency slots. Yet, every annual cycle presents a unique array of new faces, talents, experiences, and energies of candidates visiting our Ann Arbor program. This recruiting season has been particularly good, marked by nearly 70 astonishing medical students who interviewed for four residency positions to start here on July 1, 2018, as the class of 2023.

Just as we rank the students, they rank us among the other programs they like and a computer makes the binding national match. Most applicants we see will become successful urologists and most programs they rank will train them excellently, evidence that our medical schools and professional organizations have created high standards, with narrow Gaussian distributions of quality. This is to say, the very best programs and candidates falling on the right side of the curve are not grossly dissimilar by most measures from the programs and candidates on the other side. A theoretical program variability curve (blue) and wider student applicant curve (red) illustrate my belief that some applicants are potentially “better” than any of our programs. That should be no great surprise, as it indicates Darwinian principles at work: some of our successors should, by all rights and intents, surpass those of us who teach them.

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Two.
What does it take to go from applicant to successful resident? Most people we interview will become excellent residents and urologists who will impact their communities and practices significantly, and some will advance the field of urology in major ways. Before students create their preference lists, they need to get in the door for rotations and interviews. This requires good Step One board scores and excellent medical school performance data. Since most schools are “pass-fail,” applicants must demonstrate noteworthy performance in their clinical clerkships, such as “honors” in their deans’ summaries and strong letters of endorsement. When recommendations come from colleagues we know, with good track records of producing students who become excellent residents, we pay attention. Honorary society membership, selection to AOA for academic work or the Gold Humanitarianism Society, helps demarcate successful applicants. Exemplary social behavior is an important feature and successful performance on teams, such as college sports and humanitarian efforts, is also typical of our applicants.

Test metrics, honors, and accolades are surrogates for the attributes we seek in our residents and future colleagues. We want individuals with intellect, empathy, ingenuity, resilience, and good humor. Good residents and good colleagues tolerate personal inconvenience to help their patients and teams. Particular metaphors illustrate our affinities. The people we seek have the “fire in the belly” to do the daily work and to solve meaningful problems. They “go the extra mile,” or add-on the “extra case” at the end of the day when the going gets tough. We need people who work well in teams, yet are effective leaders when the opportunity or need arises. Candidates similarly seek attributes of training programs. Surveys and “field notes” over the years identify important factors in play for applicant preferences such as program depth, established mentorships, institutional culture, geography, global opportunities, and climate.

Two new features of our program will come on line. Steve and Faith Brown of California created a scholarship for a medical student, preferably from UM, entering our urology residency each year. The Brown scholarship will help residents with research projects or unique educational experiences. An intermittent 5th residency/research position, intended for a physician-scientist and established with the NIH and AUA, will start in 2019 and last seven years.

Three.
The Gaussian distribution of residency programs, narrow and steep, reflects the fact that nearly all are fully capable of preparing trainees for excellent urologic careers. The wider applicant curve reflects my belief that many of our trainees have the capacity to be better than we (the faculty) are now. In fact, this is our goal. We want to train residents who will leverage the best of what they learn and see from faculty today to improve urology practice and research throughout their ultimate careers. In their own time, today’s residents and fellows will discover new knowledge, recognize new paradigms, invent better technologies, create novel operative solutions, and find ways to deliver health care more safely, efficiently, generously, equitably, and with greater kindness. If we do our work properly, our trainees will be more adaptable and creative in the environments of their tomorrows, than we could be if we cloned ourselves.

Johann Carl Friedrich Gauss (1777-1855), the only child of a poor family, was born and raised in the Duchy of Brunswick, now Lower Saxony, Germany. A child prodigy, he attracted the interest of the Duke of Brunswick who supported his education locally and at Göttingen University. Gauss’s doctoral thesis in 1797 offered a proof of the fundamental theorem of algebra, that every polynomial equation with real or complex coefficients has as many solutions as the highest power of its variable. The duke’s philanthropic investment paid off well, as Gauss became known as “the foremost of mathematicians” (Princeps mathematicorum) and the most influential mathematician in the past millennia, impacting numerous areas of mathematics and science in general. Many echoes from Gauss’s brain reverberate today. In addition to Gaussian distribution we have the Gauss unit, Gauss law, Gauss formula, Gauss platform, Gauss elimination, Gauss-Bonnet theorem, and even the Gauss rifle. The web reveals an astonishing array of Gauss’s quotes, revealing a humorous and humanitarian mind. (Below: Daguerreotype of Gauss on his deathbed. Wikipedia.)

Four.
Universities are civilization’s best bet for its future, teaching tomorrow’s citizens and builders, and expanding today’s knowledge. Universities explore “the nature of things” and public universities play a particularly important role. A quote by David Damrosch stays with me:

“A report by the Carnegie Council in 1980 began by asking how many Western institutions have shown real staying power across time. Beginning with 1530, the date of the founding of the Lutheran Church, the authors asked how many institutions that existed then can still be found now. The authors identified sixty-six in all: the Catholic Church, the Lutheran Church, the parliaments of Iceland and of the Isle of Man – and sixty-two universities (Three Thousand Futures).” [Damrosch, D. We Scholars. Harvard University Press. 1995, p. 18.]

Purposeful building of successive generations cannot be left to chance or entirely entrusted to government, religious entities, or the private sector. Nor should this be entrusted to any single university system, whether state or private. A diversity of universities, public, private, and ecclesiastical (in collegial or sometimes sharp competition with each other) will be the best way to educate successive generations, innovate technologies, and create and test new ideas for tomorrow. Universities must accommodate the immediate milieu and stakeholders of today, while taking the long view for subsequent generations. Gauss’s university is exemplary.

The University of Göttingen was founded by King George II of England in 1734 (as Elector of Hanover) and quickly became a center for the nationalistic reawakening of the German lyric and national poetry. Encyclopaedia Britannica credits the university with releasing Germany “from the confines of the rationalism of the Enlightenment and from social convention.” Gauss studied at Göttingen from 1795 – 1798, but around its centennial in 1837 the university took a reputational hit when seven professors were fired for political unrest. Luster was restored before its bicentennial particularly at its Mathematical Institute, that Gauss had once led. Göttingen has produced 40 Nobel prize winners including Max Born, James Franck, Werner Heisenberg, and Max von Laue. The strong mix of humanities and science at the University of Göttingen is noteworthy evidence that these two facets of creativity are inseparable, divided only by parochial and unimaginative perspectives. A century younger than Göttingen, The University of Michigan is no less rich in humanities and science. All universities need to figure out better ways to merge those two fundamental sides of knowledge.

Five.

Galens 91st annual Tag Days began yesterday and will run through tomorrow. Medical students and faculty at the University of Michigan created Galens Medical Society in 1914 for student advocacy and as a social bridge between students and teachers. The name choice is both obvious and obscure. Galen was one of the early great names in medical practice and study, but it remains a mystery as to why that particular name was selected for this medical society. Galens Society at Michigan created an honor system, obtained secure student lockers (theft was a problem even in those halcyon days), and established a student lounge. In 1918 Galens members held the first Smoker, a series of skits performed by Galens men. Galens shifted its focus in 1927 to raise money for children with Tag Days, wherein students solicited faculty and community members, a tradition that continues the first weekend of December in the Medical Center and the streets of Ann Arbor. The Silver Shovel Award began in 1937 to honor faculty who have shown extraordinary commitment to teaching medical students.

At some point Galens opened its doors to women medical students, reinvigorating the organization. Galens initiated the Mott 8th floor project in 1964 to house its Workshop for Children that had been ongoing since 1928, but lacked a permanent site. A chapel and student lounge were also created in that space. Galens contributed funds for the Mott Pediatric ICU in 1968 and in the 1980s made a similar contribution to St. Joseph Mercy Hospital for its Pediatric ICU. In 2006 Galens came up with $200,000 for the Child and Family Life Playrooms in the new Mott Hospital. In addition to the Mott Child and Family Life Program, Galens has supported Ozone House, Foundations Preschool, Children’s Literacy Network, The Corner Health Center, and Special Days Camp, among other worthy projects.

Galens today includes about 120 medical students and 13 honorary faculty members. During Tag Days students on street corners sell tags that raise nearly $100,000 for Mott efforts and other children’s programs in Washtenaw County. In addition to The Smoker, Galens supports a Welcome BBQ, a tailgate, and a year-end banquet. A Galens Loan Fund helps medical students for their interviewing costs, that easily can cost students $5,000 – $10,000 as they travel around the country in their fourth-year interviewing for residency. Next year’s Smoker, by the way, will be March 2 and 3 at Lydia Mendelssohn Theatre.

Six.
Michigan men.

Francis Collins returned to Ann Arbor last month for the M Cubed Symposium and gave an inspiring talk that he called “NIH: National Institutes of Hope.” As a faculty member here in the Department of Human Genetics, his team figured out the genetic basis of cystic fibrosis. He went on to co-direct the human genome project and is currently NIH Director. Collins spoke about the considerable footprint of UM in medical research and our relatively large portion of the NIH budget.

Dr. Collins offered three reasons for splicing “hope” into the NIH acronym. First is the role of the NIH in uncovering life’s foundations; second is the NIH intent to translate discovery into health; and third is the synergy in the socialization of science, that is the idea that collaborations are the best way for the scientific community to “move forward, together.”

The NIH origin dates back to July 16, 1798 when Congress established the Marine Hospital Service “for the relief of sick and disabled Seamen,” recognizing that their healthcare was a responsibility of the government. The Marine Hospital Service fell under the Treasury Department and a monthly tax of twenty cents was deducted from the pay of merchant seamen, making this America’s first prepaid health care system. Less than a year later, legislation extended the benefits of the Marine Hospital Service to Navy and Marine Corps personnel. In 1875 a new law directed the President to appoint a Surgeon General of the Marine Hospital Service with advice and consent from Senate. Interstate quarantine authority was granted by Congress in 1890. The name of the service was changed in 1902 to the Public Health and Marine Hospital Service, eventually growing into the NIH, now intended to improve knowledge and extend services to improve health. The current budget exceeds $32 billion.

John Park was recognized as Clinician-of-the-Year at the Michigan Medicine Awards Dinner last month. A superb pediatric urologist, quintessential teacher and mentor, and leader as Surgeon-in-Chief at Mott, John is one of the most respected and beloved clinicians of Michigan Medicine. The yearly awards celebration was instituted by former dean Allen Lichter, continued by Jim Woolliscroft, and now is fine-tuned by Marschall Runge, Carol Bradford, Bishr Omary, and David Spahlinger. (Below: Park family)

Seven.
When calendar years close out, pundits tally major events and accomplishments, as if to predict what future generations might mark as notable for that year. Some events and findings this year, unrecognized by most of us likely will rise to great significance in future times. At this moment, as of December first, some breakthroughs of the year are already acclaimed as important, although much can yet happen for good or for bad this last month of the year.

Science magazine traditionally announces its “breakthrough of the year” with 9 runners-up, as a result of a “people’s choice” poll. Likely contenders for that list will be: observation of gravitational waves by three separate observatories, thereby supporting Einstein’s general relativity theory; CRISPR gene-editing to correct the mutation causing hypertrophic cardiomyopathy in a viable human embryo (similar work was reported in China a few years ago); neutron star collision (kilonova) witnessed at LIGO; and human-pig hybrid creation at Salk.

Editors and writers of Science magazine in 2016 picked the detection of gravitational waves as the breakthrough of the year announced in the December 2016 issue [Adrian Cho. The cosmos aquiver. Science. 354:1516, 2016]. Alternatively, another poll (of readers) listed the gravitational wave by the LIGO interferometer as number two, preferring as number one the breakthrough in tissue culture techniques that allow human embryos to be sustained ex vivo for nearly 2 weeks. The “people’s choice” for number 3 was portable DNA sequencers, followed by an artificial intelligence milestone for number 4, and a finding on cell senescence and aging. My point is that human biology was central to 4 out of 5 of the 2016 breakthroughs and will likely be prominent in the 2017 choices.

Eight.
December first, looking back, is noteworthy for historic airplane crashes. As the methodology of aviation checklists has been imported into medical practice, most visibly in the surgical arena, it is useful to cross-examine failures and successes in both fields. Two aviation disasters occurred on this particular day in 1974. TWA 514 crashed northwest of Dulles Airport killing all 92 on board. En route from Columbus to Washington National Airport (now Reagan) the plane was diverted to Dulles due to high crosswinds and slammed into the west slope of Mount Weather. Terminology discrepancy between flight crew and controllers, heavy down drafts, and reduced visibility from snow were blamed. U.S. Congressman Andy Jacobs, scheduled on that flight, had refused to pay a $20 seat upgrade and luckily took another plane. The same day, Northwest 6231 crashed near Stony Point, NY, killing only the three crew members flying the plane from JFK airport to Buffalo as a charter to pick up the Baltimore Colts, whose planned aircraft was grounded in Detroit by a snow storm. Failure to activate the pitot tube heater, presumably a checklist item, was the root cause, resulting erroneous airspeed readings, icing, and a stall. Both planes were Boeing 727s.

On this day in 1981 Inex-Adria Aviopromet Flight 1308, a Yugoslavian charter McDonnell Douglas MD-81 from Brnik Airport in Slovenia, crashed on approach to Ajaccio on Corsica. Air traffic control believed the plane was in a holding pattern over the sea and requested it to descend, although it was actually 9 miles inland. The crew knew the plane was over the island and was surprised at the instruction to descend from their holding pattern, repeating their uncertainty to ground control. Ajaccio Airport had no radar and flight controllers insisted on descent which took the plane right into Mont San-Pietro killing all 180 people on board. On investigation, communication confusion was named as main factor.

Coincidentally a few years later, on this particular date in 1984, NASA conducted the Controlled Impact Demonstration at Edwards Air Force Base, deliberately crashing a Boeing 720 flown remotely so as to study occupant crash survivability. (Picture below, Wikipedia.) Planes seem to be made more safely, but the human factors of miscommunication and deviation from routine procedure remain our Achilles heel.

Nine.

As the urology chair search process unfolds many people will be engaged in trying to figure out the best fit for our department. Academic medicine seems to have convoluted the process of leadership succession, but it need not be difficult. A reasonable chair candidate should be someone who can take a team from good to great. A good candidate has a track record of excellence and national respect in his or her field, particularly in the essential deliverable of the department. Chairs who have failed nationally never passed these two bars.

The key requirement of a chair is to deliver the main functionalities of the department and enhance its essential deliverable. For us, that key deliverable is state-of-the-art clinical care in all domains of urology and with accessibility for anyone in Michigan or beyond who seeks our services. The essential deliverable is the milieu for our foundational responsibility of educating the next generation of urologists and urology health care workers trained in urology. The essential deliverable is also the stimulus and laboratory for our mission of discovery and research. A chair must retain and recruit excellent faculty and staff to build stability and depth of the department’s critical units, while helping its people develop their careers and fulfill their aspirations.

Personal traits of kindness, moral center, integrity, trustworthiness, flexibility, high emotional quotient, and humor are important. These are difficult to ascertain in external applicants, while a few minor deviations noted over decades of interactions “in the trenches” can derail internal candidates. Intellectual ability to deal with stress, complexity, and ambiguity is necessary. A successful chair needs curiosity to keep up with urology, medicine in general, and the changing world as he or she guides a department. A personal sense of cosmopolitanism builds the diversity, equity, and inclusion necessary for a great team.

A number of organizational talents are critical. The chair must understand and articulate the mission of the organization, sharing its beliefs and values. The chair must listen well and understand the department’s stakeholders. The chair must build teams, develop consensus, elicit a vision, and craft strategies with stakeholders. The chair should be a proven hands-on problem solver when necessary, yet be an excellent delegator. The chair must understand the social responsibility of the organization relative to its partners, community, region, nation, and world-at-large. A chair must steward and grow the departmental resources. I came to learn these attributes from leaders of my various career stations and particularly from dean Allen Lichter and coach David Bachrach.

Ten.

What lies ahead. It may seem doubtful that many people will be talking about “the halcyon days of 2017” next year or beyond, yet who knows what lies ahead to reframe our perspective? Historians viewing certain domains such as Astros baseball, might indeed think 2017 was a golden, happy, and joyful time. Turbulence in the health care markets, the uncertainties of regulations such as MACRA, changing demographics, expanding comorbidities, domestic violence, and environmental deterioration may combine to make 2017 look better from the rear-view mirror than it seems now from our perspective in December of this year.

Secular stagnation, an idea proposed by American economist Alvin Hansen in 1938, suggested that economic progress after the Great Depression was restrained as investment opportunities were held back “by closing of the frontier and collapse of immigration” [Economist Aug 16, 2014]. The idea could be expanded to the thought that any great shock to the world-at-large is followed by a period of latency. One can only guess how historians someday will define the era in which we are presently immersed. Stagnation of human progress is evident in many parts of the world, encompassing diplomacy, human rights, food security, personal safety, health care, environmental quality, as well as economic growth. If one views the world through a dystopia lens, then tomorrow’s metaphorical glass is half empty and this year may be viewed as relatively halcyon. With a more optimistic lens, if human progress ultimately wins the day, as history indicates, the year 2017 may not appear particularly halcyon.

This year ahead will be busy for the Department of Urology at the University of Michigan. A search committee for new chair begins with strong representation from our department. John Wei, Kate Kraft, and Scott Tomlins know our department well, and the other members of the committee are terrific choices as well. Our departmental retreat, April 14, will be a good time to take stock of the process. A special meeting on bladder cancer, the Teeter Symposium, is planned for May 4. Bob Teeter, a friend of our department, lost his life to bladder cancer a decade ago and since then knowledge of the biology of this disease had advanced greatly, as have surgical and medical treatments. The symposium will be an opportunity to see how far we have come and develop some paths for the future. We look forward to the Nesbit Reception at the AUA in San Francisco, Sunday, May 20. During the Ann Arbor Art Fairs, we will host the 12th Chang Lecture on Art and Medicine on July 19 and the next day will feature Hadley Wood of the Cleveland Clinic as the Duckett Lecturer and Rosalia Misseri of Riley Children’s Hospital in Indianapolis as the Lapides Lecturer. Our Health Services Research Symposium will be September 13 and 14. The Nesbit Alumni Society meeting September 20-22 will feature our own alumnus Toby Chai, now professor of urology at Yale. The Montie Uro-oncology Lecture is planned for some time next autumn. In 2019 we begin centennial celebrations to transition into the second century of urology at the University of Michigan.

[Neighborhood leaves, in transition, 2017]

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

Matula Thoughts December 4, 2015

Posted by dabloom

DAB What’s New/Matula Thoughts

December 4, 2015

Paris, Band-Aids, & the coarse emotions of mankind

3140 words

1. December is at hand, although in the busy everyday world of clinical medicine days and seasons seem to blur. Nevertheless, clues abound that make it hard to mistake this holiday month. Above you see the second floor corridor of UM Main Hospital with decorated windows on a previous early weekend December morning. The holiday season has grown from theological roots to a cosmopolitan sensibility of advancing human welfare. This is a time of year we try to think beyond ourselves and the hunger of others is especially compelling whether in front of you on downtown streets of Ann Arbor or in the news reports from the Middle East, Africa, Asia, or South America. Food security is as much, if not more, an essential part of human welfare and health as the specific morbidities that capture our attention as specialists.

Astrologic, seasonal, and meteorological explanations of illness are residues of the more superstitious days of medicine, but with nuggets of truth these links remain in play today. The seasonal and climactic influences on human welfare and health are unquestionably substantial, and as the dinosaurs discovered large extraterrestrial bodies can impact life on Earth. Our bodies down to the cellular level pay attention to calendar, clock, and climate. Illnesses like holidays have seasonality; we know that the incidence and mortality of coronary artery disease peaks in winter and reaches a low in summer while many other conditions also have their own seasons. [Pell JP, Cobb SM. Quarterly J. Med 92:689, 1999] Then, of course, there is the “July effect,” the enduring speculation that it’s risky to be ill in the hospital when new house officers start on the job. Happily today it’s December and all our house officers are well seasoned.

A 1984 music video from the movement called Band Aid “Do they know it’s Christmas?” is a 4-minute classic that is as fresh today as it was 31 years ago – you can find it on YouTube. The supergroup, formed by Bob Geldof of the Irish band Boomtown Rats, raised over $24 million for famine relief in Ethiopia with the video. The most recent incarnation, Band Aid 30, raised funds for 2014 Ebola victims and prevention.

2. We humans, uniquely among all species, are intensely emotional and inquisitive about our health. Healthcare in any season is a matter of attending to small and large problems, from Band Aids to urosepsis 24 hours a day, seven days a week, and each of us needs help from time to time attending to these problems. Victorian novelist George Eliot wrote: “What do we live for, if not to make life less difficult for each other?” This may not be a universal human sentiment, but it surely is a key part of a good physician’s credo and any society must have good physicians. Healthcare workers naturally prefer fixing medical problems and otherwise helping their patients rather than completing electronic medical records or collecting RVUs. Healthcare is also a matter of teaching patients (and learning ourselves) how to live healthier and manage the morbidities and comorbidities of life. We do this work individually, in teams, and across the larger geopolitical world. Tempting as it is, even as specialists in the comfort of our specialized fields, we can’t ignore that larger geopolitical realm. Our urologic cocoon is a fulfilling workspace, yet we have no choice but to also attend to the geopolitical space through curiosity about events around us, by speaking out, and leading when we can. The world is predictably disruptive and explosive, as witnessed just last month in many places from Mali to Paris, the latter more properly an epicenter for peace, as with the Treaty of Paris of 1763 (ending our French and Indian War), the Treaty of 1898 (ending the Spanish American War), and more recent attempts to restore international order.

The 2015 United Nations Climate Change Conference is now meeting in Paris (Nov 30-Dec 11), nearly coincidental in timing to the recent terrorism events. This is the 21st annual meeting of a team that aims to achieve a legally binding and universal international agreement to reduce greenhouse gases and to contain global temperature within 2 degrees Celsius of pre-industrial levels. Forward-looking businesses are starting to recognize the simultaneous necessity and business opportunities of global stewardship.

3. On this day, 4 December, in 1918 President Woodrow Wilson crossed the Atlantic for WWI peace talks in Versailles, a suburb of Paris. That made him the first US president to travel to Europe while in office. After a trip back home for 3 weeks in February he returned to Versailles for the duration of the talks until June. Wilson’s personal physician Cary Grayson accompanied him on both trips and remained with him the whole time in France. The outcome of the talks was the Versailles Treaty of Peace with its inclusion of the League of Nations. Wilson believed in the League of Nations as a hedge against future conflict and on his final return home (shown below) undertook a nationwide tour to campaign for the treaty, but suffered a stroke in October of 1919. Grayson and Mrs. Wilson masked the severity of the stroke from the government and the public, while Senate Republicans opposed the treaty. Henry Cabot Lodge proposed a compromise that Wilson refused. Ultimately the Senate rejected the treaty and the U.S. never joined the League of Nations. Wilson’s internationalism didn’t take hold in the USA, but his efforts were admired internationally with the Nobel Peace Prize in 1919.

Wilson wasn’t at his best in those days with urologic issues in addition to the stroke. Severe benign prostatic hypertrophy (BPH) with urinary retention further hampered his effectiveness as a politician in that critical time. In the days when our Journal of Urology attended to matters of urologic history, an excellent paper by Fogg, Kutikov, Uzzo, and Canter addressed this interlude of Wilson’s health. [J Urol 2011, 186:1153] Historical scrutiny has also revealed Wilson’s paradoxical gaps as a humanist. His racial views and employment decisions, whether as President of Princeton or of the United States, although considered “centrist” for early 20th century America, were strongly bigoted against non-whites and non-Christians. [Berg AS. Wilson. 2013. The case against Woodrow Wilson. New York Times. Editorial November 25, 2015]

4. North of Paris by 24 miles sits the Musée Condé and library at the Château de Chantilly in Oise, housing the manuscript Très Riches Heures du Duc de Berry with its beautifully illustrated monthly panels. The December panel is remarkable. While traditional iconography for the Christmas season would feature a more nostalgic visual, this panel shows the more visceral details of dogs dismembering a boar after a hunt with the Château de Vincennes of Charles V on the horizon and the trees curiously still in leaf (a warm winter?). The castle still stands in that Parisian suburb. The scene, as in all the Duc de Berry illuminations, depicts everyday agrarian life with people going about their daily business. Illness, disability, and intimate details of healthcare, urologic issues most particularly, were too indelicate for such public display, although such aspects of everyday life were real concerns for everyone then as they are today.

Urology has progressed with technology and new knowledge, yet it remains focused on its genitourinary geography, staked out in ancient Egyptian times with urethral catheterization, in Hippocratic days with lithotomy, and in the nineteenth century with cystoscopy. Gone are the days of Frère Jacques Beaulieu, the itinerant lithotomist, who travelled throughout France in the early 18^th century with his “certificates of cure” and removed agonizing bladder stones with his secretive technique. [JP Ganem, CC Carson. J Urol 1999;161:1067]

Nowadays, urologists work in teams and seek innovation for their own practices while freely disseminating their ideas and techniques to others. Urology, at least as much as the other core facets of medical practice, is a social business. President Wilson’s urologic issues would be treated better and more expeditiously today, and even better tomorrow with, perhaps, the histotripsy technology pioneered here in Ann Arbor by Will Roberts and his team of biomedical engineers and radiologists.

5. Like many of our faculty, I’ve been on the road this autumn in that pursuit of new ideas and knowledge, in addition to dealing with the clinical and administrative work flows at home. In Irvine, California at Ralph Clayman’s festschrift I heard state of the art talks on stone disease. Ralph seems glad to be back to the real world of urology after his five years of good service as medical school dean. In Nijmegen, Netherlands I participated in the 50^th anniversary of the excellent Radboud University Medical Center urology unit. Their discovery, education, and clinical work is world-class, and the visit gave me some thoughts related to our impending 100 year anniversary of Michigan Urology. The American College of Surgeons, with its annual meeting in Chicago this fall, is an important avenue of engagement for urologists from the educational, discovery, and public policy perspectives. A visiting professorship in Portland, Oregon game me a chance to see another superb department of urology, formerly headed by John Barry and currently by Chris Amling. My colleague Steve Skoog leads the pediatric urology team, our former medical student Sarah Hecht is performing well there as a resident, and some of our finest Michigan Urology graduates are leading in the regional practice of urology. Steven Steinberg was Michigan’s contribution from the McGuire days here in Ann Arbor and Rou and Jeff are more recent Nesbitonians.

[Nesbit alumni Jeff Wheat and Rou Wang, now of Portland, during my visit]

In Baltimore the 100^th anniversary of the Brady Institute coincided with the Clinical Society meeting hosted by Alan Partin and Pat Walsh. We heard superb presentations from Hopkins faculty, including Ken Pienta (formerly with us in Ann Arbor) and Nobelist Carol Greider who discussed her work on telomeres. She extolled the virtue of “curiosity-driven research” and told how her work was inspired by investigations of Tertrahymena thermophila. (In this odd single celled animal, with only 40,000 chromosomes, the telomere was recognized as tandemly repeated hexanucleotide sequences.) [EH Blackburn, JG Gall. J Molec Biol 1978;120:33] A number of Michigan names showed up in slides of other talks presented in Baltimore: Chinnaiyan, Feng, Tomlins, and Roberts, for example. Hopkins’ new clinical facilities are lovely and functional, yet they have artfully left strong structural remnants of their rich history as a storied urology department.

[Picture: Carol Greider advocating curiosity-driven research and showing slide noting that “New discoveries come from unlikely places”]

6. Ann Arbor’s first snowfall took place this year, somewhat early, on November 21. With winter many plants go dormant and others self-destruct, while most of us animals simply endure the cold and prepare for the next warmer seasons. What’s New, our monthly newsletter, is getting ready for a new calendar year. This communication began in the dean’s office of Allen Lichter around 2001 and morphed into a Urology Department weekly profile of individuals and teams in 2007. On the first Friday of each month we have carved out an issue for my gratuitous thoughts. Nearly 3 years ago we mounted a simultaneous version of the first Friday piece on a blog site and called it Matula Thoughts, with the idea that older pieces could be archived and that the communication could be accessed more easily than email that has become too crowded and too painful a place for most of us to linger. The blog site (wordpress) also allows us to visual the reach of this monthly habit of our Department of Urology.

[Above, 2015 blog visitors, geographic distribution. Below, histogram of last 3 years.]

For me this communication is a periodic Band-Aid for the excessive emails, endless Twitter feeds, and other electronic distractors. Matula Thoughts also provokes curiosity, for example, with the word Band-Aid, that you might consider a brand name. Invented as recently as 1920, the story goes that Earle Dickson (1892-1961), a cotton buyer at Johnson & Johnson, had a wife named Josephine who often cut or burned herself while doing housework and cooking. His handmade prototype (squares of gauze kept in place by crinoline on a roll of tape) allowed Josephine to manage her own wounds. Dickson continued to refine his product and by 1924 the company had a machine that could mass-produce sterile adhesive bandages. With trademark genericization Band-Aid lost its protective status and became a generic term for all adhesive bandages.

[Thank you Wikipedia. Our annual $100 contribution is in your bank for 2015, and no doubt you’ll need another one in 2016. “The Story Behind Band-Aid Brand” Changing Times; The Kiplinger Magazine December 1964: p. 32]

7. In 2016 we will begin a new iteration of administrative structure at the University of Michigan Medical School and Health System. Except for a several year interlude after February 1930 when the regents fired Hugh Cabot as dean (he was Michigan’s founding urologist-educator), the University of Michigan Medical School has always had a dean. On January 1,2016 the duties of the dean will be added directly to the job description of Executive Vice President for Medical Affairs, Marschall Runge. We must thank our outgoing dean, Jim Woolliscroft, for his 8 years in associate dean positions and 9 years of service as dean. Jim has been a superb internist, educator, and statesman of medicine. We hope he will remain with us for in these tricky times and turbulent socioeconomic waters we need his good counsel and intellect. The clinical chairs established an annual lectureship on medical education in Jim’s name and a perpetual full tuition medical student scholarship. [Picture below Jim Woolliscroft and his early mentor and previous chair of Internal Medicine at Michigan, Bill Kelly at the UM vs. MSU game this autumn]

[Picture above: Clinical chairs & Dean Woolliscroft after presentation of Woolliscroft Lectureship and Scholarship]

8. Preview of 2016. I can’t predict much of anything for the upcoming year, other than to say we should expect the unexpected – we should anticipate surprises that may be planetary and in our ecosphere, geopolitical and terroristic, economic, healthcare related, regional, and intramural here at the University of Michigan. We can’t change the occurrence of most of these events, but we can reinforce our values and rehearse our responses. A recent article in Pediatrics by Plant, Barone, Serwint, and Butani called “Taking humanism back to the bedside” concludes with a quotation from George Eliot in Middlemarch that might help reset our humanism thermostats [Pediatrics, 2015; 136:828].

“We do not expect people to be deeply moved by what is not unusual. That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind and perhaps our frames could hardly bear much of it. If we had a keen vision and feeling of all of human life, it would be like hearing the grass grow and the squirrels’ heartbeat, and we should die of that roar which lies on the other side of silence. As it is the quickest of us walk about well wadded with stupidity.”

George Eliot was the pen name of Mary Ann Evans (1819-1880) about whom much more could be said than space now permits. Her only known photograph is an albumen print from around 1865 and held in Paris at the Bibliothèque Nationale.

9. Beaches. On that recent trip to Portland, Oregon as visiting professor, my friend Steve Skoog (former resident of mine at Walter Reed and subsequently our Duckett lecturer here in Ann Arbor) took us to Cannon Beach, where we saw Haystack Rock, shown above. Beaches like this are places to find relaxation, recreation, and inspiration among the waves, seaweed, seagulls, crabs, fish, and bivalves that are doing their daily jobs. We all need moments to unwind and walk around, although perhaps not so obtusely as Eliot believed “well wadded in our stupidity.” For us humans, the beach is expected to be a place of peace, so we are shocked when we encounter perversity there in the form of fatal riptides, tsunamis, the terrifying fiction of Jaws, or real sporadic shark attacks. The predicted rise of the oceans should give us pause as well. Perversity is a word that fits nicely here, meaning something so wrong that it is strange or offensive. Such things are wrongheaded, that is turned away from that which is right or good. Perversity is something that is obstinate in opposing what is reasonable or good. Perversity persistently intrudes on humanity, as we have seen most recently in Paris.

10. By now most people have forgotten Aylan Kurdi the 2-year old boy who drowned with his mother and 4-year old brother in the Mediterranean off the coast of Turkey while fleeing the civil war in their native Syria. Their intended destination was the island of Kos. This was the site of the Hippocratic School of health, education, and the enduring oath 2.5 millennia earlier. Perversely, the bitter irony of the image of Aylan Kurdi lying on a beach to the east 20 miles away is less enduring in our minds than shark attacks in the recent news. Shark attacks on humans occur on an infinitesimally small scale and the Kurdi family tragedy is just one of millions this year alone. How can it be that our brains lead us to fear sharks more than ourselves?

The innocent suffer the most from mankind’s follies such as self-righteous tyrants, political and religious zealots, bigotry, corporate greed, failed national policies, and diplomatic breakdown. The staggering numbers of international refugees (60 million by last count and half of these are children) will exhaust all nations. Any solution to this crisis, if there is to be a solution, is not a matter of expanded quotas in kindly nations. Solution is beyond the ability of any sovereign nation. The solution requires strong international agency that demands national responsibility and accountability, enforces national borders, stewards human future by means of planetary sustainability, and protects the common man above all ideologies, religions, economic theories, biases, and disputes. Wilson’s League of Nations was a valiant, but failed attempt. The United Nations of today is a weak work in progress, although clearly better than nothing as we hope for a favorable outcome of the human experiment. We need some sort of vaccination against the ideological and sectarian viruses for which human brains seem so susceptible. The current crisis of 60 million refugees fleeing civil wars hasn’t been enough to galvanize international response. Greater crises are likely to come from instability of climate, geology, cosmos, and terrorism. With 2016 at hand, we have to hope our species can get its act together soon. While science will provide some tools to that end the essential political solutions will come from educated and humanistic world citizens. Art, in particular, can pull us out of the cocoons of daily life and serve as an antidote to our “well wadded stupidity” for in the words of George Eliot: “That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind.”

Thanks for reading What’s New and Matula Thoughts and best wishes for 2016.

David A. Bloom

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