Graduate medical education

Politics, as usual?

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Matula Thoughts March 5, 2021

2987 words

Politics, as usual?

One.

Last month was Lincoln’s birthday and a new biography, Abe by David Reynolds, merits comment. Fundamental issues of Lincoln’s times remain fundamental issues today and Reynold’s book permits you to be a “fly on the wall” in the rooms where consequential things happened. You need not be historian, constitutional lawyer, or elected politician to weigh in on these issues – literacy in today’s complex world is an existential necessity, political literacy for health care professionals in particular. 

Lincoln took office at an extraordinary moment of bitter partisanship and threat to the nation. His first inauguration was preceded by ugly political fighting amidst divisive and turbulent social conditions that Lincoln navigated deftly, although sometimes uncertainly. Many ideologies, “isms” and factions created a toxic climate that divided the nation into uncompromising strongholds of opinions as to which way the country should go. Lincoln was the consensus choice of the voters, but his perceived ideology was contentious to a vocal minority.

A recent article by historian Ted Widmer tells how on February 13, 1860 (a day after Lincoln’s 51st birthday) a mob tried to enter the Capital to disrupt the confirmation of the election. The mob, lacking passes to enter the Capital (and ignoring how American democracy was intended to work with peaceful transfer of presidency), was blocked by soldiers and protested loudly outside the building. Tempers also flared inside House and Senate chambers but American democracy and Lincoln won that day at the Capital. [T. Widmer, NYT, Jan 10, 2021.]

Reynolds argues convincingly that Lincoln distilled the toxic climate of opinions and centered his political course on the central defining idea of the nation as he saw it,

“.. Slavery, he declared in August 1856, ‘should be not only the greatest question, but very nearly the sole question.’ Noting the diversionary tactics of the proslavery side, he stated, ‘Our opponents, however, prefer that this should not be the case.’ He again drove home his main point: ‘The question is simply this – should slavery be spread into the new territories or not? This is the naked question.

Along with the naked question went a central idea. ‘Our government rests in public opinion … Public opinion, on any subject, always has a central idea, from which all its minor thoughts radiate. That central idea in our political public opinion, at the beginning was, and until recently has continued to be, the equality of men.” [D. S. Reynolds, Abe, Penguin Press, 2020, p. 434-435.]

This was a historically sound and prescient argument. Lincoln boiled down the entire national acrimony to the single organizing (and aspirational) principle of the Declaration of Independence – human equality.

Inasmuch as the Declaration was the primary justification for the new nation, it was an obvious corollary for Lincoln that the nation could not be divided, leading him to the famous biblical reference in his House Divided speech of June 1858. 

“ ‘A house divided against itself cannot stand.’

I believe this government cannot endure, permanently half slave and half free.

I do not expect the Union to be dissolved – I do not believe the house to fall – but I do believe it will cease to be divided. It will become all one thing, or all another.” D.H. Donald, Lincoln. Simon & Shuster, NY 1995. p.206.]

For all the subsequent debate over the conflict between the aspirations of the Founders and the ugly facts of “state’s rights” to hold human beings as “property,” the reality is that neither the Declaration nor the Constitution provided for such personal rights to own property in human beings – a concept totally dissonant from the foundational mandate and words of the Declaration.

Both documents had required consensus among all 13 colonies. Three provisions of the Constitution reflected the wills of slave-holding states, yet the document deftly steered clear of asserting any claim to the noxious idea of human slavery itself – “property in man.”

The first Constitutional provision (Article I, Section 2) allowed for congressional representation and apportionment of taxes for the states based on their “respective Numbers” of “free Persons” (these were assumed to be white men only, although that was never explicitly stated) plus:

“…those bound to Service for a Term of Years, and excluding Indians not taxed, three fifths of all other Persons.”

This cynical inclusion gave the slaveholding states the extra edge of additional votes and tax reapportionment for three-fifths of all enslaved persons. Ultimately these provisions were obliterated by the Thirteenth and Fourteen Amendments.

The second provision, another bone thrown to the slaveholding states, came in Article 1, Section 9 but it was time-limited.

“The migration of Importation of such Persons as any of the States now existing shall think proper to admit, shall not be prohibited by the Congress prior to the Year one thousand eight hundred and eight, but a tax or duty may be imposed on such Importation, not exceeding ten dollars for each Person.”

The final provision is in Article IV Section 2:

“No person held to service or labor in one state, under the laws thereof, escaping into another, shall, in consequence of any law or regulation therein, be discharged from such service or labor, but shall be delivered up on claim of the party to whom such service or labor may be due.” 

The framers of the Constitution clearly expected “property in man” to wither away, little expecting the Missouri Compromise of 1820 would allow the inclusion of a new slaveholding state and the Kansas-Nebraska Act of 1854 would allow the “popular sovereignty” of new states to make their own decisions on the matter. Rather than withering away slaveholding was resurgent in the days leading up to Lincoln’s first term and civil war was inevitable.

Lincoln set a course for the war with principle and perseverance, although as it ground on undecidedly, the Union will flagged and Lincoln feared for his reelection. By July 1863 the tide turned, in spite of draft riots in NYC, and Union victories in Vicksburg and Gettysburg fueled optimism. In August the president decided to sit for a picture.

Photographs in those days required long exposures, lasting many seconds or minutes and, as Lincoln sat for a glass plate portrait in August 1863 at Alexander Gardner’s studio in Washington, a fly alighted on the president’s trouser leg below his right knee. Lincoln was unperturbed and continued to sit still for the photograph, without troubling the insect. [Above: Gardner’s photo. Below: detail of the famous fly under Lincoln’s knee on the posterior crease.] 

 

Two.

Health care in Lincoln’s time hardly compares to health care today, but the matters of human inequality in terms of life, liberty, and the pursuit of happiness underpin our modern acrimony just as they underpinned the great national dilemma in 1860, especially so today in matters of health care. [Above: Harper Hospital, original hospital complex in an 1884 drawing  710 of The history of Detroit and Michigan or, the metropolis illustrated …, by Silas Farmer p. 710. British Library.]

In Lincoln’s lifetime it was unusual for a person anywhere in the world to go into a hospital. Medical care was delivered in doctor’s offices, people’s homes, or on battlefields. Hospitals offered very little to their unfortunate patients, aside from a bed. Lincoln died just when the germ theory emerged from Ignaz Semmelweis, Louis Pasteur, and Joseph Lister. The medical world was starting to change. During the Lincoln presidency, Ann Arbor had no hospitals, while Detroit had several, the newest being Harper Hospital, built in 1863, largely to attend to soldiers injured during the Civil War. 

Health care reflects the values and aspirations of economic and political systems of any given community and society. Modern nations seem to be see-sawing between democratic rule and authoritarian/central rule. Yet this is not a simple bipolar contest. Democratic rule provides elected representatives to express “the will of the people” but requires significant central/federal authority that may verge toward authoritarian leadership (as was claimed during FDR’s presidency on numerous occasions). Authoritarian control of a society responds poorly to the needs of the people, stifling education, inquiry, and innovation but is ultimately (and ironically) contingent on acceptance of that authority by enough people in the society (as revolutions have proven again and again). As Lincoln said, our government rests on public opinion. And public opinion should be informed by basic Constitutional literacy. 

A scathing critique of modern hospital care is recounted in the recent small book by noted historian Timothy Snyder, Our Malady. Lessons in Liberty from a Hospital Diary. He offers the provocative opinion that liberty in the political sense and health care in personal terms are directly linked, gleaning that perspective from his near-fatal illnesses and suboptimal hospital care.

“America is supposed to be about freedom, but illness and fear render us less free. To be free is to become ourselves, to move through the world following our values and desires. Freedom is impossible when we are too ill to conceive of happiness and too weak to pursue it. The word freedom is hypocritical when spoken by the people who create the conditions that leave us sick and powerless. If our federal government and our commercial medicine make us unhealthy, they are making us unfree.”

 

Three.

Freedom of enterprise and thought have brought great accomplishments in medicine and science but not a unified system of heath care. We often are told “Our health care system is broken” but the  complaint is not quite right. No purposeful system exists, rather a variety of organizations and systems that have evolved in response to the myriad needs and challenges of healthcare. Each system may work well enough for its purposes and stakeholders, but they function independently, often in competition with other systems and their stakeholders. The common good of the public, individually and at-large, tends to be a secondary concern. The “broken system” complaint, although misconstrued, is relevant and global. The individual patient is the ultimate stakeholder, but gets lost in the systems. 

Health care should be many things – accessible, equitable, effective, efficient, timely, safe, kind, and universal. But it usually falls short. This is obvious to 7 billion people –  advantaged and disadvantaged populations alike. Local, regional, and global inequities are visible every day on public streets or in countless newsfeeds. Even if your individual health care seems secure, it is precarious – predicated on a job, a bank account, health status, social status or caste, location, family member, public safety, and other particularities.

The frameworks of healthcare organizations reflect the values that underpin them in each locality and their nations. Most perform adequately in terms of their business success, some excellently, but few do well in the matters of personal care, coordination, excellence, equity, and value. Business success (revenue optimization) is not the primary purpose of non-profit healthcare organizations. That’s not why society grants them no-for-profit status.

The State of California recently sued Sutter Health for anticompetitive practices that raised the cost of health care in northern California for little reason beyond increase in revenue. 

We, the public, should care about this. Most large health care organizations enjoy the benefit of “non profit” status. The public gives these organizations tax breaks that are not given to “for profit” organizations like Amazon, Exxon, or Johnson and Johnson, that have a central defining objective of maximizing shareholder value. “For profit” organizations of course have other protections carved out by the public, notably limited liability status, that enhance their abilities to succeed in the business world, but “not-for-profits” serve larger public values.

 

Four. 

Management by accounting uses performance metrics and these have spread into the non-profit sector, health care in particular. Metric domination tends to deform missions. When governing boards use performance incentives to inspire a CEO, CFO, or CMO to cut nursing positions, eliminate overtime, or decrease benefits, then those things are likely to happen even if they damage the quality of products, the performance of employees down the ladder, or the culture of organizations. The entire brand of any organization is at risk, not-for-profits especially. Governing boards optimally should govern and not manage (and micromanage) their organizations. They need wise management leaders with holistic (and accountable) reign over their domains in the organization to best advance the mission of the enterprise, which naturally involves financial responsibility but not to the detriment of mission or brand. [Above: bean counting. Illustration from Margarita philosophica, 1503, by Gregor Reisch (d. 1525). Houghton Library, Harvard University.] 

Financial responsibility in health care, essential as it is, cannot not be constrained to the next quarter’s balance between revenue and expenses. Immediate “financial margin” is important, but no less essential are quality, value, stakeholder satisfaction, financial liquidity, investment in enterprise strategy, investment in research and innovation, health care education, debt leverage, leadership succession, community responsibility, workforce health-retention-recruitment, organizational culture, policy development, public health, etc.

Health care is a huge and complex bucket of obligation in the modern world, far too complex for any of its myriad organizations to be primarily managed by key performance indicators or incentive directives.

 

Five.

Presidential inaugurations used to occur at this time of year because slow communications and clumsy political processes of this nation in its earlier history required at least four months from national elections to the peaceful transition of power that distinguished the American experiment in democracy.

The first inauguration, that of George Washington, took place on April 30, 1789, but subsequent ones occurred in March until March 4, 1933, the last March presidential inauguration, when Franklin Roosevelt replaced Herbert Hoover (above) – after a contentious election in the dark days of the Great Depression, but the two statesmen executed a graceful transfer of power in the finest tradition of American Democracy.

New technologies of communication and shortened news cycle in Roosevelt terms allowed inaugurations to be moved to January –  the second inauguration of Roosevelt was the first of these after the Twentieth Amendment to the U.S. Constitution moved the beginning and ending of presidential, vice presidential, and congressional terms from March 4 to January 20.

The past presidential election degenerated into fraudulent claims of voting irregularity, dozens of dismissed lawsuits to overturn results, and efforts to block the transition of power by congressional mischief or threat of armed force. The election results were counted, recounted, inspected, certified, and ligated over two months, but cynics may seek to restore that original prolonged interval between actual election and inauguration to allow more time for shenanigans.

Unfortunately, something so important as political leadership falls into the hands of all sorts of men and women called politicians, whom history proves again and again cannot be uniformly trusted to “do the right thing.”

This ultimately comes down to personal assessment, but what are the right things? Are they the right things for politicians, their constituencies, or the right things for society at large? The answers comes back to the Declaration and Constitution: life, liberty, and pursuit of happiness with Constitutional fidelity. This means fair and equitable education, justice, public health and safety, and opportunity.  Much of this is measurable with public health and safety data, poverty statistics, crime rates, equity in housing and education, and “happiness” ratings such as Likert score surveys.

Roosevelt’s four terms derived from democratic elections and he functioned with a strong hand, discovering new essential federal roles in rebuilding a nation from economic collapse and then guiding it successfully (along with much of the rest of the world’s nations) through a massive war. Hitler, in contrast,  manipulated his appointed position as chancellor into authoritarian rule that precipitated and lost that war, incurring unimaginable devastation in his 12 years as dictator.

Political systems, transcending individual leaders and terms, are essential to carry out the “will of the people” and protect them from threats whether they be human threats, economic threats, biologic threats, or environmental threats. Political literacy is an existential necessity. 

 

Postscript.

On the walls.

Metaphoric elevation of lowly and annoying houseflies (Musca domestica) to miniature sentient journalists imagines the precarious nature of the invertebrate, in imminent danger of destruction by authoritarian swat. [Above: Housefly, Wikipedia.] 

A related metaphor, the bugging of a room, came to life in the real world and literary genres of crime and spy stories. 

After President Obama successfully eliminated an annoying fly during a CNBC interview in June 2009 a number of journalists recalled Lincoln’s greater tolerance in August 1863. The organization People for the Ethical Treatment of Animals (PETA) chastised Obama mildly and sent him a “handy-dandy bug catcher” according to its newsletter Animals Are Not Ours. [Alisa Mullins, “Obama and the fly,” June 17, 2009.] 

This was not President Obama’s last public brush with the unruly insect order, it happened again in January 2013 during a White House briefing when he announced his selections to head the Securities and Exchange Commission and the Consumer Financial Protection Bureau. An emboldened fly briefly alighted on Obama’s forehead, but escaped to buzz another day, although journalists were quick to record the event. Vice President Pence, among countless others, also had his historic moment with Musca domestica, at the October 2020 Vice Presidential debate, once again showing that politicians sometimes tolerate flies on the walls and bugs in the rooms where things happen.

American re-enlightenment. The George Floyd moment of 2020 illuminated much of the American condition from its original sins to present disparities that so impact the aspirations of life, liberty, and the pursuit of happiness.

My friend and Army colleague, pediatric surgeon Victor Garcia, recently sent me a book by a teacher at his alma mater, West Point, Ty Seidule. Robert E. Lee and Me. A Southerner’s Reckoning with the Myth of the Lost Cause. This timely book, explains how attitudes are formed in cultures, how they persist, and how or why they can change. [T. Seidule, St, Martin’s Press, NY. 2021.]

The difficulty of changing beliefs and myths – through rational argument, historical analysis, and scientific process – is an existential challenge that our species seems to be failing. Flies on the walls watch and invertebrates may yet win the day on this planet, even though Homo sapiens is capable of doing so much better. 

Thanks for looking at Matula Thoughts, March 5, 2021.

David A. Bloom

University of Michigan, Department of Urology

 

 

Expectations and epistolaries

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Matula Thoughts
January 1, 2021
Expectations and Epistolaries

2941 words

One.

Calendar reset. After all the hoopla, brouhaha, and general ruckus, today’s customary greeting “Happy New Year” looks ahead with optimism. Human nature, on the other hand, nudges us to also look backward with caution, Janus-like. One year ago, few people expected 2020 would be dominated by a tiny RNA virus. Clues were present but, even without those signals and others soon following, common sense alone should have kept us, vulnerable species that we are, on guard for recurring global pandemics, the last massive one having been only a century ago. [Above: Janus, Wikipedia, source Vatican.]

Some argue that the present pandemic is more accurately described as a syndemic: an unfortunate coincidence of a global infectious disease and a range of noncontagious comorbidities. The term came from medical anthropologist Merrill Singer in the 1990s, referring specifically to the interactions among substance abuse, violence, and AIDS (SAVA). Syndemic now denotes occurrences of multiple categories of disease interacting in specific populations. The Lancet expanded the concept for a new series in the journal beginning in 2017. [The Lancet, 389:881, 2017.] A Lancet article this autumn discussed the syndemic nature of COVID-19 in India and the dangers of false optimism as restrictions were lifted there in June. [The Lancet, 396:867, 2020.] In syndemic terms the COVID-19 situation is an acute respiratory viral condition interacting with an array of noncommunicable diseases (NCDs) that tend to cluster within social groups. The key operative words here are respiratory viral infection and social groups (social translates to behavioral, economic and caste). DOI:https://doi.org/10.1016/S0140-6736(20)32000-6

It is beyond ironic that, when the worldwide COVID deaths reached one million by the end of September last year, the United States accounted for 20% of fatalities although representing only 4.25% of the world’s population and arguably possessing much of the world’s best resources to contain the virus. Lacking in this country were national leadership, public trust, and the good will and sense of its people to take sensible measures to minimize spread of a somewhat fragile and moderately contagious virus, SARS-CoV-2.

 

Two.

Expectations. History shows that uncertainty about what a new year will bring is nothing new. New years bring gains, losses, and some recoveries as I’ve seen while researching the story of Michigan Urology with far more discovered than two books and Matula Thoughts could contain. One letter found in the Bentley Library fits this January essay nicely: a note sent by UM Medical School Dean Victor Vaughan to his friend Dr. Arnold Lorand in Karlsbad, Czecho-Slovackia, written January 12, 1920. The two friends had lost touch during the terrible war that disrupted their lives, as it had millions of others. They were lucky to reconnect. 

“Dear Doctor:-
Mrs. Vaughan and I were much pleased to receive your Christmas card. We have often wondered what had become of you, and we have often expressed the wish that we might look down upon Karlsbad, its splendid mountains, and its beautiful walks, many of which awaken in us pleasant memories. We have gone through the dreadful cycline [‘cyclone’], I and my five sons were in the Army, and my oldest son now rests in French soil. I often wonder whether I will ever desire to visit Europe again. However this may be, we remember you with the greatest pleasure, and we send you best wishes, not only for the coming year, but as we hope, for the many years to come. Yours truly, V.C. Vaughan.”

Lorand (1865-1943) was a physician at the Carlsbad Spa, longevity researcher, and pioneer of modern geriatric medicine. His 1911 book, Old Age Deferred, was popular in America and went through a number of printings. [New England Med Gazette, 47:845, 1912.] He was one of many academic friends gained and visited by the Vaughans during their lives, and epistolaries such as Vaughan’s were the common way people kept in touch, taking more time and crafting than today’s phone calls, emails, or texts. [Below: Lorand and 1913 edition of his book.] 

In 1919, with the end of WWI in sight, the Vaughans looked forward to better times as they returned from military duty in Washington, DC to Ann Arbor, but grief followed that summer when their son “Clarence” drowned accidentally while swimming in a river in France, just as troops were drawing down near the end of the war. Dean Vaughan had gotten the news while at the American Medical Association national meeting in Atlantic City in mid-June 1919, just as he was to chair a session. After a few moments to collect himself he stepped onto the stage and took the chair. It was also during this meeting that Vaughan first met Hugh Cabot who had recently returned from more than two years on the Western Front in France serving with the British Expeditionary Forces. Allied Powers and Germany ended their conflict and signed the Treaty of Versailles on June 28, 1919, but within the next 20 years, Germany would break its postwar agreements, subsume Czechoslovakia, and initiate another world war.

After a difficult 1919, the Vaughans hoped for a happier 1920 and the Christmas Card from the Lorands was a happy signal.

 

Three.

Little things, unnoticed by most people at this first moment of 2021, may become consequential to us in the near future, just as they did last year and every previous new year. The little things may be microorganisms, memes, or people. For example, few in Ann Arbor noticed in January 1933 when Adolph Hitler became chancellor of Germany, although the world soon took note. Many people admired his German patriotism in the dark days after the Treaty of Versailles with his ability to energize domestic industry and get railroads to run on time, but autocratic governance and tyranny never serve a people well and end badly.

In contrast, the 1933 presidential inauguration of Franklin Delano Roosevelt on March 4 was universally noticed throughout Ann Arbor and beyond, marking a turning point in the Depression, although his new administration disturbed many conservative citizens. Where Reed Nesbit stood on this issue can only be imagined as he was not as public with his political beliefs as had been his mentor, Hugh Cabot. Nesbit, however, seemed always to favor the common man.

Roosevelt may not have been a “common man”  but his disability brought him close to the myriad daily struggles of common people. Few Americans knew, at this time, that FDR needed assistance to stand and walk, due to polio, it had been believed, incurred in 1921 although a modern view suggests that Guillain-Barré was the more likely cause. [Below: a scene unimaginable in 2021 – Herbert Hoover and Roosevelt together enroute to 1933 inauguration. Library of Congress.]

In retrospect those 1933 transitions began a new chapter in the recurring contest between democratic rule and authoritarian rule, in this instance precipitated largely by the residue of WWI and the Great Depression. Which system best solves a nation’s problems and improves the lives of its people? Hitler exploited his nation with coercion and physical force, while Roosevelt deployed a lucky mix of democratic process, capitalistic enterprise, “New Deal” big government, and moral authority. The public, the press, and academia took far too little notice of this contest until it spilled over into another world war that would give democratic ideas and humanity another reprieve. Cats have a finite number of lives, but we hope democracies have more. 

 

Four.

Annus mirabilis. In January 1971 Jack Lapides began his second year as Section Head of Urology and it was an extraordinary one. As someone who had grown up in Depression times, served in the Pacific in WWII, and seen university and national politics up close, Jack was no “Polly Anna.” Yet, while cautious of threats ahead politically, economically, and globally he relished the opportunities of his new position and robust ideas. 

Now, a half century later, it is tempting to try to understand his thoughts as 1971 opened up. Just like today, that New Year began on a Friday. This would be the year Lapides broadcast his ideas on clean intermittent catheterization (CIC) that at the time contradicted medical convention, initially bringing him more ridicule than praise. Nonetheless the concept proved worthy, opening the door to a new era of surgical urinary tract reconstruction and improving the lives of hundreds of thousands of people with urinary tract dysfunction globally.  A generation later, leaders like Bernie Churchill in Toronto equated Lapides’s retrograde idea to the most “Nobel Prize worthy concept” in urology.
https://doi.org/10.1016/j.juro.2016.10.080

Lapides (above) published nine papers in 1971 and was appearing on the national center stages of urology regularly just as his predecessors at UM, Hugh Cabot and Reed Nesbit had in their times. At the American Urological Association (AUA) annual meeting in Chicago, May 16, 1971, Lapides moderated a panel called “What Constitutes a Good Urological Residency,” consisting of Peter L. Scardino of Savannah (father of our friend Peter T. Scardino), Clarence Hodges of Portland Oregon (trainee of actual Nobel Prize winner Charles Huggins of UM and then the University of Chicago; later mentor of John Barry), Ralph A. Straffon of Cleveland Clinic (trainee of Reed Nesbit), W.V. Tynes of Norfolk, J.J. Buchierre of Rochester MN, and John Hall of Ann Arbor (chief resident at UM). 

The UM urology brand was in wide display at the 1971 AUA in Chicago. Notably, the chairman of the Society of Pediatric Urology that year was Ian M. Thompson, formerly from Ann Arbor, but currently chair in Columbia, Missouri. The 1971 AUA Meredith Campbell lecturer, Willard E. Goodwin of UCLA (a friend and supporter of Lapides) spoke on “Some hermaphrodites, pseudohermaphrodites, ambisexuals, and other ambiguous types I have known.” An “Ask the professor” session featured Goodwin and John J. Murphy urology chief at the University of Pennsylvania. Murphy was a 1952 graduate of the Nesbit program. Residents on the podium “grilled” the professors about their training and absorption into the field of urology, and “seemed to have the feeling somehow that they had been misguided in a urologic career.” [AUA Centennial History Vol. 1 p. 58.]

That oddly negative view of those residents was not repeated the following years nor did it seem to indicate a trend. Lapides’s trainees in Ann Arbor harbored nothing less than great respect and admiration for their chief and experiences in Ann Arbor, as based on my recent conversations with many of them. In the summer of 1971 Charles Adams, Sahir Cittan, John Gambee, and the late Ed Tank completed their urology training at UM while Robert Barnett, Thomas Kub, Thomas Newman, Lee Underwood, and Robert Vinson began their three years of residency under Lapides. I began my training at UCLA that summer, falling under Goodwin’s spell and far from ever feeling misguided considered myself lucky to be there. Sadly 1971 was the year that Jack’s wife, Alice, passed away.

 

Five.

Ups and downs. A half century ago, 1971, was a great year for an ascending Jack Lapides, but it was a tipping point into despair for another UM alumnus who lost faith in his own future, and indeed the future of our species. This individual dropped out of the conventional world and stepped off the so-called grid to a hermit-like existence in a cabin he built in rural Lincoln, Montana, much in the manner of Henry David Thoreau, or so it seemed at first. The modern-day recluse, however, had far darker thoughts, believing that industrial society could not control its own future and would destroy not only our species, but all others and the planet around us. These ideas took over his brain like a virus and led him to believe that the only recourse was to mail bombs to people targeted as symbolic in industrial society. He anonymously delivered at least 16 bombs that maimed and killed a number of people between 1978 and 1995, becoming known and feared as The Unabomber. In 1995 he sent the New York Times a letter promising to suspend his campaign of terrorism if it printed a rambling essay he included, “Industrial Society and its Future.” Meanwhile, a large FBI team at work since 1978 had failed to identify this “Mad Bomber,” until his brother became suspicious enough to supply the critical tip that led to arrest in 1996 and current imprisonment.

That incoherent essay of Ted Kaczynski (UM Mathematics Ph.D. 1967) has been reformulated to a book, Technological Slavery, available on Amazon where it is described blandly.

“Logical, lucid and direct, Technological Slavery is more than an expansion on the ideas set forth by Theodore Kaczynski in Industrial Society and its Future (aka ‘The Manifesto’). It radically reinvigorates and reforms the intellectual foundations of an age-old and resurgent world view: ‘Progress is a myth. Wild nature and humanity (including human freedom, dignity, and autonomy) are fundamentally incompatible with technological growth.”

Kaczynski is now incarcerated at Federal Prison ADX in Florence, Colorado, serving a life sentence for his murderous campaign, and receives no remuneration for the book. 

Considering our ineptitude as a species and society in dealing with many existential crises  – pandemics, terrorism, extreme weather, earthquakes, environmental deterioration, poverty, food insecurity, economic and social inequality, ongoing regional warfare and destructive geopolitical conflict – it is no huge surprise that a small subset of our 7 billion people become unhinged by reality. To be so certain of belief and driven to terrorize others by mayhem and murder as Kaczynski, however, is clearly far beyond the pale. And others follow, notably Anthony Warner, last week in Nashville. [Below: Pales of settlement; Ireland 1488 and 1901 Poland and Russia. Wikipedia.]


Surely there are myriad constructive ways to build better futures for ourselves and the planet, although we’d better find them more quickly as the opportunities are slipping away.

No one can fully know what 2021 will bring, but we can predict some things will be lost this year: for a start – certainly much glacial ice and rain forest, and likely some essential species. Whatever other critical events we ignore at our peril – time will tell.

 

Postscripts.

Letters to self. We sent What’s New by email for 20 years and continue to publish the web version, Matula Thoughts, on the internet (maulathoughts.org) on the first Friday of each month.

What’s New, the communication, began in Allen Lichter’s Dean’s Office of UM Medical School in 2001. Some in the office then believed that “we can’t communicate too much” whereas others felt burned-out from the daily barrage of “Too Much Information” on physical and electronic desktops. The idea of producing something predictable but not too frequent, while interesting (one hoped) and reasonably concise, seemed preferable to random uncurated attachments and messages. We began What’s New then at predictable monthly intervals (first Fridays) to provide a finite “weekend read,” of around 15 minutes. The essay transitioned to the Urology Department in 2007 with the web version (easier to access and manage if “followed” on the website) in 2013 as matulathoughts.org making this number 95. 

The Dean’s Office of Faculty Affairs, now in the capable hands of Brian Zink, and the Department of Urology, under the excellent stewardship of Ganesh Palapattu, are creating their own modes of communication to fit their new times. Matula Thoughts continues a monthly cadence of essays relating loosely to medicine, Michigan, urology, biology, or other matters in the cabinet of curiosities, from a professor making the final round of bases in the game of academic medicine. This year seems a good time to free up people’s email and liberate many from an unwanted monthly weekend assignment, so we will discontinue the email distribution of What’s New. We will, however, continue the web format Matula Thoughts, that can be accessed by the click of a button on the web site, providing a monthly email and link to matulathoughts.org.

Trees fall in forests. 

Why write these essays? The essayist Michel de Montaigne (1533-1592) was an initial inspiration and exemplary modern expressions of the urge to communicate in writing are flourishing. Even if few people in the forest witness the falling tree of an essay, it serves a primal purpose. [Above: Hartwick Pines State Park, Grayling, Michigan, September 2020.]

Comparing the essay form to the nearly-obsolete hand-written letter, the author Claire Messud commented:

“The review and the essay remain a more public, yet ideally still intimate, version of the epistolary. Not a place to share one’s private details, to be sure, but certainly to try to communicate, as precisely and with as much complexity as possible, one’s experience of a work of art, or the evolution of one’s thought….” [C. Messud, Kant’s Little Prussian Head & Other Reasons Why I Write. W.W. Norton, NY, 2020, p. xx.]

A letter assumes an audience, usually of one, although not necessarily of anyone. The act of writing provides a measure of satisfaction and deliverance (of an observation) even if it is simply a “note to self.” Messud’s book is both “an autobiography in essays,” as it’s self-described, followed by a collection of 16 literary and visual art contemplations, but most importantly, one suspects, it is an extraordinary series of personal notes-to-self that bring clarity to the writer. 

Metrics
Nothing is beyond the pale on the internet and much of it is measurable. Matula Thoughts took a small dip when the author ceased to be departmental chair of urology at UM in 2019 but readership is back with a rise this year with views at 3458, 3357, and 3929 (31 Dec.) for 2018, 2019, and 2020. This past year 16 countries produced 10 or more “views’ and another 55 countries had “single digit visitors” – enough observers in the cyber forest to justify continuing Matula Thoughts for 2021. Of course, “a view” or “a visitor” is not necessarily a thoughtful reader, but merely a measure of notice within the forest and, happily in terms of forest sustainability, Matula Thoughts doesn’t require many falling trees. Nonetheless, after nearly 20 years of this essay, it remains primarily a “letter-to-self,” if only an affirmation of self that sometimes resonates with someone else. [Below: Word Press readership for Matula Thoughts 2020.]

Thanks for reading Matula Thoughts this January 2021.
David A. Bloom

 

December

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Matula Thoughts

December 4, 2020

Change and hope

2810 words

One.

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

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

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

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

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

 

Two.

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

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

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

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

 

Three.

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

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

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

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

 

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

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

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

 

Four.  

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

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

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

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

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

 

Five.

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

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

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

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

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

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

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

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

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

 

Postscript.

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

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

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

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

Thanks for reading Matula Thoughts this December, 2020.

David A. Bloom, University of Michigan Department of Urology

 

Autumn leaves and certitude

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Matula Thoughts 6 November 2020
4129 words



One.

Autumn leaves and Nobel Prizes normally highlight this season, although Covid, climate, and a consequential national election dominated our attention this year. The award in Medicine or Physiology last month, however, went for discoveries relating to the hepatitis C virus.

That curious terminology of medicine or physiology is a historic reminder how science was disrupting health care when the Nobel awards began in 1901. A new certainty of physiology and other scientific disciplines, explaining the basis of normal biological function and disease back then, is now widely accepted in the 21st century, although we realize that the optimal practice of medicine in addition to its scientific basis also requires art and humanism. [Above: autumn leaves, Ann Arbor westside, 2020. Below: Nobel Prize medal.]

Politics are also in the air this month, even more unpleasantly than usual, and the Nobel awards are no less political than other human enterprises. Conflicts over these prizes have involved nearly all fields including that of Medicine or Physiology. The 1923 prize to Frederick Banting and John Macleod for the discovery of insulin outrageously excluded Charles Best and James Collip. Honorably, the two named prizewinners independently split their monetary shares with Best and Collip. No award was presented in 1925; the two main contenders, Johannes Fibiger and Katsusaburo Yamagiwa, had been proposed separately as the first to induce cancer in laboratory animals, but both were branded “undeserving” with great certainty by a key member of the award committee. Fibiger had used a roundworm he called Spiroptera carcinoma (Gongylonema neoplasticum) to cause stomach cancer in rats and Yamagiwa used coal tar to create cancer on rabbit ears. After further deliberation the following year, the prize went to Fibiger, although in durable fact Yamagiwa’s work was by far the better proof of principle of chemical carcinogenesis. Nonetheless, Fibiger was the first to get this Nobel Prize for work related to cancer. The second time this happened was in 1966 when Reed Nesbit’s first urology trainee, Charles Huggins, shared the award with Peyton Rous.

The Nobel Foundation offended Adolf Hitler when it awarded the Peace Prize in 1935 to Carl von Ossietzky, the journalist who exposed the clandestine German rearmament, illegal according to the Treaty of Versailles. von Ossietzky, a Roman Catholic, had been detained and beaten in German prisons and concentration camps since February, 1933, and was hospitalized with tuberculosis when the award was announced. Hermann Göring ordered von Ossietzky to refuse the award and the Nazi regime prevented travel to Stockholm but, in an act of civil disobedience, von Ossietzky issued a note accepting the Peace Prize. The ugly politics caused two committee members to resign and Norwegian King Haakon VII dodged the ceremony, even though the recipient could not attend. von Ossietzky died in 1938 while hospitalized under Gestapo surveillance.

In February 1953 Watson and Crick assembled an accurate model of the structure of deoxyribonucleic acid (DNA). Rosalind Franklin’s x-ray diffraction images, shown to Watson by Wilkins, provided the “eureka moment” in which the double helix configuration was realized. Watson and Crick were recognized for this with a Nobel Prize in 1962, that they shared with Wilkins. Franklin, however, having died of ovarian cancer in 1958, never learned of her role in the breakthrough and, by virtue of the rules of the Nobel Prize, was ineligible because she was no longer living.


Two.

[Above: Newton, by William Blake, 1805. Tate Museum.]

Certainty 1.0. Craving certainty, we derived it for most of human history from personal observations, beliefs, and the authorities of the times. A Matula Thoughts correspondent from Georgia raised the matter of moral certainty last month, quoting H.L. Mencken on the issue:

“Moral certainty is always a matter of cultural inferiority. The more uncivilized the man, the surer he is that he knows precisely what is right and what is wrong. All human progress, even in morals, has been the work of men who have doubted the current moral values, not of men who have whooped them up and tried to enforce them. The truly civilized man is always skeptical and tolerant, in this field as in all others. His culture is based on ‘I am not too sure.’” [Minority Report: H.L. Mencken’s Notebooks (1956).]

Morality and certainty, historically, were inseparable for most of humanity, hardwired in cultures and written into laws of churches, states, and organizations. Morality, as a topic, is far beyond scholarly consideration of this set of essays, but certainty is a matter of keen concern in health care. Philosophers, religious leaders, royalty, politicians, have offered their versions of certainty over millennia, but certitude challenges easy universal agreement, as one’s certainty on an issue is based on one’s origin, belief system, willingness to reason, and livelihood. Mencken, Lewis Sinclair, C.E.M. Joad, and others have variably said: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

From a practical perspective as a physician, certainty means belief without rational grounds for distrust. Medical practice demands that conclusions must be drawn with certainty, for example, from urine specimens whether in matulas, under microscopes, via chemical strips, or on culture plates. Urologists, as all practitioners, depend upon certainty in diagnosis and therapy, yet we cannot be absolutely certain about everything that passes under our visage. Relative certainty is a practical and essential qualification. [Below: Constantine examines urine in matulas. 11th c. Wikipedia.]

Mencken (1880-1956), influential journalist and social critic known as the Sage of Baltimore, could turn a phrase well, but he represented a peculiar elitism and exceptionalism of the first half of the American 20th century. Self-assured in his certainty, he often was acerbic and dismissive to those he perceived as lesser intellect or “lower caste,” although he didn’t use that terminology. Mencken was contemptuous of Franklin Roosevelt, argued against the New Deal, objected to U.S. participation in WWII, and harbored admiration for the Nazi regime. Ayn Rand was one of his great admirers, but other influential voices were critical. Christopher Hitchens later offered a scathing opinion of Mencken in a book review.

“How did one of America’s seemingly great rationalists and modernists come to regard Roosevelt as more worthy of condemnation than Hitler? The answer, on the evidence of this and other studies, is that Mencken was a German nationalist, an insecure small-town petit-bourgeois, a childless hypochondriac with what seems on the evidence of these pages to have been a room temperature libido, an anti humanist as much as an atheist, a man prone to hyperbole and sensationalism he distrusted in others and not as easy with the modern world and its many temptations and diversions as he liked it to be supposed.”

Hitchens also turned his phrases well, but when he hit, he struck hard and unsparingly. [Hitchens, “A Smart Set of One,” The New York Times (17 November 2002), book review of The Skeptic: A Life of H. L. Mencken (2002) by Terry Teachout.]

Certainty, although personally comforting, closes the mind to new ideas and leads to smugness. It is irrational to expect 7 billion people to share the same certainties about all matters, short of a limited number of generally-accepted facts, such as that days follow nights, the moon has phases, eclipses occur occasionally, kindness and civility are nice, and some things such as infanticide and cannibalism are grotesque. The first rule of certainty, however, is that change is inevitable and accordingly, uncertainty rules above all.


Three.

Uncertainty. Werner Heisenberg made uncertainty respectable when his concept of indeterminacy (on a very small scale) in 1927 garnered him the 1932 Nobel Prize. Erwin Schrödinger carried the idea to the visible world in 1935 with his famous thought-experiment and paradoxical cat. [Above: Heisenberg c. 1901; Below: Schrödinger c. 1933. Wikipedia.]




[Above: Movable silhouette of Schrödinger’s fictional cat in the garden at Huttenstrasse 9, in Zurich where he once lived; visitors outside the walls cannot know the cat’s position or its direction, at any moment. Wikipedia.]

Uncertainty entered the moral dimension and popular culture, it could be argued, with Bryan Cranston’s fictional character Walter White in the Vince Gilligan television series of 2008. White, a modern-day high school chemistry teacher, is followed over five television seasons “breaking bad” into a dark world of the manufacture and distribution of 96% “pure” methamphetamine. White’s nickname Heisenberg initially conveyed his good state as a brilliant chemistry teacher, but the full irony came out when Walter turned to his dark side as a meth kingpin. [Below: Breaking Bad publicity still, Walter White.]

Mencken’s caution of self-certainty and promotion of “I’m not too sure” belied a number of other outrageous statements, defaulting to intemperate self-certainty, and forgetting his own restraint of “I’m not too sure.” Some Menckenisms reflected primal certainty that trumped morality and civility, such as “Every normal man must be tempted, at times, to spit upon his hands, hoist the black flag, and begin slitting throats.” [Mencken, The New Poetry Movement, Chapter 6.] [Below: Jolly Roger Flag.]

Momentary reversion to the primitive pirate in everyman – casting off the morality and mores of humanity, whether in thought-experiment or actuality – can’t be blamed on Mencken. He articulated the idea well, but it hardly originated or ended with him, and homicide remains widely evident in fact and fiction; even if we do not choose to be murderous outlaws, we relish them in our entertainment.

It comes as a surprise, now, 20 years into the 21st century, to find widespread craving for authoritarian rule. Possibly, this is propelled by a growing sense of nihilism where too many people prefer the certainty of “I don’t really care except for what’s good for me” over the uncertainty of “I’m not too sure.”


Four.

Independent thought. Modern society seemed to be gravitating toward the intellectual relativism of “I’m not too sure,” although maybe that was my wishful thinking.

It is reasonable to believe that throughout human history most people prayed for relief from authoritarian subjugation by clan leaders, priests, pharaohs, princes, kings, queens, and dictators. Those few leaders dictated their personal certainties to everyone else, claiming authority derived from physical strength, bullying, divine authorization, bloodline, caste, national exceptionalism, political sectarianism, or other “isms.” Physical intimidation in authoritarian societies suppresses expression of uncertainty and even more effectively, the memes of sectarian “isms” act as ideological viruses replicating the certainty of patterned thoughts in individual minds and crowds, precluding reasoning and doubt.

People, perhaps most, chafe under authoritarian rule, although they may do so silently. The contrary meme of the pirate, openly rebuking authority of the establishment, always finds sympathy in regulated societies, even those not authoritarian and repressive. An interesting example is the island of Corsica, variably contested by many authoritarian nations over the centuries and now French, proudly displays its counter-cultural pirate symbol on flag and coat of arms. [Below: Corsican symbols of independence.]


Mental acrobatics that lead to certainty are sometimes called heuristics and, aside from crude mapping by functional MRI, the neural gymnastics at play defy our best imagination and science. It is more convenient to be told what things are certain than to be figuring them out in every step of life’s way. Our historic predecessors – early humans lacking today’s sharpened tools of logic, science, and debate – must have found comfort to be given explanations for solar eclipses, earthquakes, or monsoons by tribal leaders or village priests, rather than tremble at the uncertainty of it all.

The problem with human thinking nowadays seems to be the matter of how people deal with their sense of “I’m not too sure.” Methodological thinking, analysis of information, and fair discussion can help people understand what to be sure of, what to question, and how to decide. However, these instruments of education, science and free speech are only effective when we step outside the comfort of our particular certainties and open our minds to other opinions, information, rational debate, and experiments of thought and science. Too often, we revert to the easier dogma of our sects and certainty our leaders.

The Good Doctor, a new book by our Georgian colleague, examines the importance of uncertainty in medical practice; no good physician can be a know-it-all. On the other hand, nobody wants an ambivalent doctor who offers a list of ten possible diagnoses and ten potential remedies and tells us to choose what we prefer. [K. Brigham, M.M.E. Johns, The Good Doctor, Why Medical Uncertainty Matters. Seven Stories Press, NY, 2020.]

A relevant thought comes from professor Sarah Buss here in the UM Philosophy Department who explains to her students that they can’t gain a deeper understanding of issues they consider in class without becoming less certain where they stand on those issues: “I aim to help them gain clarity, knowing that the result will often be a loss of certainty.” Professor Buss, in turn, quotes colleague Kieran Setiya:

“The patience to ask and to keep asking questions, without the assurance of agreement or the availability of methods apt to elicit it, is the philosopher’s gift. It is an expression of intellectual hope, and the repudiation of philosophy is a counsel of despair.”

[K. Setiya. Monk Justice. London Review of Books. 42 (16), 30 Aug. 2018.]

For everyday events on the human scale, in space and time, things are usually one way or another. We are used to uncertainty in life, but we prefer predictability, whether in elections, horseracing, or surgical outcomes. In fact, we depend on some degree of certainty, even if it is the probability of knowing the odds of a specific throw of dice or hand of cards, assuming fairness of the event. Statistics for a condition or certain state within a group, however, doesn’t translate well to a particular person for whom having the condition or state is a personal possibility of “yes” or “no,” that is a 50% probably in their mental calculus.

Adjectives and numbers help arbitrate uncertainty. Even simple adjectives, as in the world of genetic diseases, may offer precision. For example, “rare” conditions are said to affect less than 62/100,000 people while “ultrarare” has come to mean fewer than 2/100,000. [J.M. Friedman et al, “Exome sequencing and clinical diagnosis,” JAMA, 324:627, 2020.] By this terminology hypospadias is not so rare (2 in 500 male births), while cloacal exstrophy is ultrarare (1 in 250,000 births). A recent zoom visiting professorship to our pediatric urology division from Katherine Hubert Chan of Riley Children’s Hospital, offered a lesson on graphics in surgical decision-making, utilizing icon arrays to demonstrate frequency of a given condition. Pictographs nicely convey a sense of likelihood or unlikelihood without the abstruse jargon of high-voltage statistical tools. [Below: an icon array.]

Five.

Certainty 2.0. At some point we humans admitted a new form of certainty into our minds, basing belief on rational argument, verifiable evidence, and experiment, rather than anecdote and authority. Paradoxically, this new certainty is based on acceptance of some uncertainty that facts and models change as we interrogate them. Nonetheless this should not allow a lazy retreat to anarchy and nihilism where nothing is held true.

Certainty is desirable in surgical practice; when treating stones, congenital malformations, or malignancies, specific identification of a problem is closely linked to beneficial solution. Yet knowledge and technologies change and yesterday’s certainty becomes today’s uncertainty, thereby reintroducing the questions, how do we know what is correct and how should we act today?

Hugh Cabot, founder of urology at Michigan and man of great certainty, took wide interest in medicine, often crossing epistemological boundaries to study and collaborate outside of his field. Working with pathologists on a paper on gastric cancer in the era of the Nobel controversy, Cabot and fellow faculty member George Adie had published their thoughts on its etiology in 1925, quoting views of their colleague, Aldred Warthin. [H. Cabot and G. C. Adie, “Etiology of Cancer of the Stomach,” Annals of Surgery 82 (1925): 86–108.] William Mayo, another physician with an Ann Arbor connection (UMMS, 1883), was also interested in the topic, writing a lead article in Surgery, Gynecology and Obstetrics in 1912 that discussed treatment from his point of view: “Cancer of the stomach: its surgical cure.” [SG&O, 14 (2): 115-119.] Mayo criticized lengthy diagnostic interludes that allow the disease to progress from “week to week” until by the time a practitioner has absolute certainty of the diagnosis before referring to patient to Rochester, “This is not a case for the surgeon, but for the undertaker.” Mayo concluded: “Cancer of the stomach is the most frequent and most hopeless form of cancer in the human body. Early operation affords the victim the only chance of a cure.” Time and discovery have altered the certainty of those conclusions. Ironically, gastric cancer took Mayo’s life at age 78.

The rapidly changing conditions, information, and misinformation surrounding Covid-19 have challenged medical certainty and public certainty. Political iniquity and social media mischief accelerate the uncertainty and miscertainty. Rather than dwell on this here, we offer two essential articles from NEJM, both accessible at no charge on the internet.
One editorial says it all. “Dying in a leadership vacuum,” [NEJM, 2020; 383:1479-1480.] A perspective by J.N. Rosenquist, “The stress of Bayesian medicine – uncomfortable uncertainty in the face of Covid-19.” [https://www.nejm.org/doi/pdf/10.1056/NEJMp2018857?articleTools=true]

Postscript.

Frank Legacki, legendary Michigan Swim Team Captain of the Class of 1961, successful businessman, and friend of the University of Michigan Musical Society and Department of Urology, passed away last month on 10/16/2020, leaving his wife, Alicia Torres. [Above: Frank at Steve’s Deli, September 23, 2020.]

Born 9/28/1939, Frank grew up in a tough Philadelphia neighborhood, the oldest of eight children – six boys and two girls. His parents, of modest means, believed in education and raised the children firmly and proud of their background and opportunities. Dad, a Polish immigrant, was a carpenter. Mom, daughter of Irish immigrants, deftly managed the large family. Frank attended Father Judge High School, where by luck and hard work, joined the rudimentary swimming team his freshman year. Lacking a pool at the school, Frank and teammates trained at pools as much as 1.5 hours away. Swimming was the glue that kept him focused in high school and he became a National Catholic High School Champion and a Scholastic All-American, earning athletic scholarships at several universities. Narrowing his choices to the University of Michigan and Ohio State University, both with top Collegiate Swimming programs, Frank asked his high school coach which school to attend. The coach answered, “Probably Ohio State, Michigan is far more difficult academically and you may have problems getting through at Michigan.” Frank decided on the spot to go to Michigan. 

Education and swimming at UM shaped his life. Eligible for the team in his sophomore year, 1959, Frank became NCAA Champion in the 100-yard freestyle and anchored the winning 400-yard freestyle relay. Two weeks later at the US Open Championship (later called the National AAU Championships) he set the American record in the butterfly. Michigan’s score of 95.5 at that competition was a new record and solidified the UM 1959 Swim Team as the greatest in NCAA history. Frank and his team continued to win and set records, and he was elected captain in his senior year, receiving other honors and leadership positions outside of athletics. Frank married after graduation in 1961 and stayed in Ann Arbor for an additional year to get an M.B.A. The couple would have four daughters, divorcing after 23 years.

A business career took Frank to New York City at Ogilvy & Mather Advertising. He went on to executive positions as: Managing Director of the Strategic Consulting Group of Marketing Corporation of America; VP of Marketing for Converse Athletic Footwear; Founder and President of the Andover Consulting Group; and President of Kaepa Athletic Footwear. Frank led a buy-out of this last company and eventually sold Kaepa to Umbro Sports Apparel. During these years he returned to UM for an M.B.A., graduating in the top quarter of the class.

In the business world Frank met Alicia Torres in San Antonio in the autumn of 1993 and they became business friends and then partners. Organizing a leveraged buyout of software products, and they formed Rosebud Solutions, generating outside investments, building a skilled team, and growing the business. Their partnership became personal and they grew close, marrying in Philadelphia on August 8, 1998, and then relocating in Ann Arbor. Rosebud was acquired by McKesson, Inc. (NYSE: MCK) in 2008. Frank went on to work part-time with Fletcher Spaght, Inc., a Boston venture capital firm, eventually retiring fully.

Frank, always loyal and grateful to UM, often said: “I was born at the University of Michigan; it was here I learned how to think.” In Ann Arbor, Frank and Alicia immersed themselves deeply in university matters and the community, enlarging their network of friends and interests. Frank was recognized for his achievements by induction into the University of Michigan Hall of Honor and The Pennsylvania Sports Hall of Fame. He stayed active with the University as President of the Grey Whales (Swim Boosters); Board of M Club Letter winners; UM Alumni Association Board; UM Urology Department Board; and Chair of the Marketing Committee of the University Musical Society. Frank was also President of the Barton Hills Maintenance Corporation. Frank and Alicia regularly attended over 20 UMS performances annually as well as School of Music Theater and Dance events. They generously supported Michigan Theater and were regular presences at UM athletic events, with season tickets for Football, Basketball, Hockey, Wrestling, Softball, and Swimming meets. Active fishermen, they cast lines in Florida and exotic locations around the world. Frank loved his time with grandchildren, Sam, Sophia, and Noah, taking them fishing, to UM events, and cooking together. The kids loved “GP Frank.”

Frank shared his rich and full years generously with friends, family, neighbors, and the University of Michigan. Alicia recounts:

“Frank had an amazing life. He gave much more than was given to him, and celebrated life like very few. He loved keeping in touch with elementary, high school, and college friends and those he met during his career and travels. Frank asked strangers about their life, where they were from and then, they too became Frank’s friends. Through his travels, Frank always carried an extra U of M cap, which he would give to people who captured his heart. When Frank entered a room, he owned it, you knew he was there, in a good way.”

Paul Legacki from Sacramento, Frank’s last living brother, was a frequent visitor to Ann Arbor in Frank’s final year. Frank anticipated his final days gracefully and with good humor, requesting his epitaph be borrowed from the last lines in Edmond Rostand’s great play, Cyrano de Bergerac. In the final scene Cyrano lies in Roxanne’s arms, mortally wounded and weakening, as he looks at Roxanne and says his final words; “They have taken my life, but they have not taken my panache.” Frank lived an active and interesting life, with extraordinary panache.

In one of the sweet coincidences of life, the lovely home of Frank and Alicia is situated exactly between those of Ananias Diokno (Nesbit 1970) and Kate Kraft (Nesbit faculty 2011), and across the street from the former home of Ed McGuire who succeeded Nesbit’s direct successor as Urology Section Chief in 1983, Jack Lapides (Nesbit 1950). Ananias and Kate’s family looked over Frank in his last days. Many of us lost an extraordinary friend when Frank died. His passing, at a young and robust 81 years of age of metastatic prostate cancer, reminds us painfully that we still have a long way to go in our work in urology.


Additional Postscripts.

The Lasker Awards were held back this year due to the Covid-19 pandemic. These are awarded annually since 1945 to living persons who have made major contributions to medical science or performed public service on behalf of medicine. This year the Foundation instead highlighted the 29 awards given in the past that recognized advances in infectious diseases, the first of those going to John F. Mahoney in 1946 for treatment of syphilis with penicillin and the most recent to Douglas Lowy and John Schiller for vaccination to prevent HPV in 2017. [J.L. Goldstein, JAMA September 25, 2020.]. My bet for a 2021 Lasker Award will be on Anthony Fauci for his tireless and courageous representation of scientific truth in the public interest in turbulent times.

Apocryphal Keynes quotations: “When the facts change, I change my mind. What do you do sir?” or “When someone persuades me that I am wrong, I change my mind. What do you do?” Variants of these have been attributed to redoubtable British economist John Maynard Keynes (1883 -1946), but no direct sourcing has been found. Nobel laureate Paul Samuelson and others alluded to versions of the remark, long after Keynes died. Whatever actual the source, it is an enlightened human idea.

True fact. Face masks diminish respiratory germ transmission by respiratory droplets. This is certain and has been clear to every surgeon, nurse, and OR worker on the planet for well over a century. Argument on this point is futile and malintented.

[Above: Justin Dimick and Hari Nathan, UM Surgery Department. Below: Aditya Pandey & Paul Park UM Neurosurgery Department.]

Thanks for looking at Matula Thoughts this November, 2020.
David A. Bloom
Department of Urology, University of Michigan

Quilting bees and blues

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WN/MT October 2, 2020
Quilting bees and blues
2392 words

One.

 

 

 

October Blues. Historically at this time of year, the blues came from regret over the loss of summer and the expected hunkering-down for winter ahead in the northern hemisphere. October 2020, however, finds most of the world already hunkered down for Covid-19. Students had another cause for October Blues, after the emotional rush of new school terms in September gave way to the “boring” routines of schoolwork, boredom that is now a matter of fond nostalgia.

No one can reasonably deny that schooling is essential to pass along skills and knowledge to successive generations. The processes and environments of schooling, in all its forms, also provide opportunities to improve the actual knowledge and skills, as well as forge community values. The present pandemic reaffirms that schools are a cornerstone of society at K-12 levels for socialization of students and for liberation of parents to do their daytime work. Higher education and the myriad forms of schooling beyond traditional schools are no less essential, but sharply compromised by pandemics that, recurring as we know well, should not take us so completely by surprise.

The Quilting Bee (above) shows a community passing along skills, knowledge, and values through an organized tradition. The painter, Anna Mary Robertson “Grandma” Moses (1860-1961), started to paint seriously at age 78, completing The Quilting Bee in 1950. Quiltmaking and quilting bees, also called quilting frolics, were good ways for communities to dispel their situational blues. Quiltmakers have transcended cultures from the earliest known quilts around 3400 BCE in the Egyptian First Dynasty to more recent times in this country. Enslaved Africans, New England Quakers, Hawaiian natives (shown below), and Amish communities in Pennsylvania, Ohio, and Indiana, among countless others, developed quilting expertise, passing along methodologies, and improving the art across generations. [Niihauan quiltmakers, photograph by Francis Sinclair, 1885, Wikipedia.]

 

Stephen and Faith Brown, UM alumni and friends of the Urology Department, followed their serendipitous interest to become expert collectors of Amish quilts, exhibiting their quilts at the UM Art Museum, the Renwick Gallery, the University of Kansas, the Denver Art Museum, and the de Young Museum. The unexpected bold colors and patterns of those quilts contradicts the restrained lifestyle of the artisans and surely must have dispelled their blues while enhancing their sense of community. [Exhibit at Renwick. Copyright Faith and Stephen Brown.]

 

 

 

Two.

 

Succession and success. Skills, arts, and knowledge of quiltmakers, soldiers, archeologists, urologists, and other workers of all sorts survive only through their successors. Virtually every discipline ensures its succession through role-modeling, education, and training, prospering when the processes of succession are deliberate.

At this time of year, medical students are anxiously sorting out their career paths and seniors are taking specialty rotations and applying to training programs. Last year’s seniors are now residents-in-training at Michigan Medicine in the fourth month of what was once called “internship,” currently labeled postgraduate year one (PGY 1) in the jargon and long line of continuing medical education (CME). [Above: Terra Cotta Soldiers of Qin Shi Huang, first Emperor of China, c. 210 BCE. Below: successive UMMS class pictures in UH corridor.]

 

The Department of Urology, as any recruiting discipline, has the double duty of selling itself to applicants while also appraising them for abilities to succeed in training and practice. Equally important, we want to build our team in urology while enhancing its diversity. We have a strong track record in this work from the days of Program Directors Gary Faerber and Khaled Hafez, and currently Kate Kraft and Sapan Ambani (all shown below).

Gary Faerber (Nesbit alumnus 1989 – now a professor at Duke.)

 


Khaled Hafez (Nesbit alum 2004)

 


Kate Kraft (Nesbit faculty 2011)

 


Sapan Ambani (Nesbit alum 2014)

 


We had no idea, last year at this time, that interview days wouldn’t take place as usual this season, when digital surfaces will reduce the full human dimensionality day-long experience to constrained transactional computer sessions. Zoom will dominate until society-at-large equilibrates with Covid-19 so we can resume a more human interview process.


Three.

Hopes and dreams. What do residency applicants want? Overall, they want a five-year learning and living experience that will bring them happiness and success, although each individual defines these conditions uniquely.

What do the faculty, current residents and fellows, and staff want? They want bright, industrious, and dependable learners and workers who will be successful in their training and in their careers. From its start in the 1920s, UM Urology has trained people to advance the discipline through care of patients, creation of new knowledge, and teaching of sequential generations. Shared values of integrity, kindness, leadership, and citizenship have been modeled and reinforced in our community of work and learning for nearly 100 years.

For the many applicants to UM Urology, we can offer only a few positions. Selection is necessary, but identification and ranking of top applicants is painfully imprecise. Applicants similarly need to assess the training programs in the national match process and for them as well, no ideal formula, algorithm, set of experiences, or scores, predicts success. Guidance from “experts” at gauging successful outcome is a forlorn hope and appraisal by each party comes down to personal holistic consideration, that is gestalt. During recruiting seasons as department chair, I wished we could have taken many more applicants, as I saw potential for success in training and in life within most candidates. While the matching process is currently an embarrassment of riches for training programs, it is a matter of life-altering consequence for each applicant.

 

A painting in 1886 called Hope by George Frederic Watts (1817-1904), captures the complexity of the predicament: a blindfolded woman sitting on a globe plays a lyre with only a single string remaining. Possibly she retains optimism in spite of obvious handicaps. Perhaps she is content but realistic. We can only guess the artist’s intent, but regardless of the nature of her thinking and sense of hope, the scene certainly is suffused with the blues. [Above: Tate Museum].


Four.

Prediction. The UM Bentley Library contains great riches – we have seen this in our study of the UM Urology history. One exchange of letters between UMMS Dean Victor Vaughan and a physician in Marion Ohio, named Fillmore Young, in July 1919, centered on the question of “Why some succeed, while others fail” in medicine. Young intended to give a paper on the topic and wrote to Vaughan, as “one of about fifteen of the prominent men of our profession who have succeeded,” asking for three indicators of success. As an example, Young quoted three predictors from the prominent American surgeon, Nicholas Senn (1844-1908).
“First: He knew his business.
Second: He asked no outside advice.
Third: He demanded his position.”

Senn’s dogmatic, inflexible, and self-assured advice was ridiculous, largely the antithesis of any responsible advice for success. Vaughan’s reply (shown below) revealed a greater mind and kinder person.
“Dear Sir;
In my opinion, there are three qualifications essential to success. The first of these is intelligence; the second is industry and the third is integrity. Fortunately most men are born into the world with a good degree of potential intelligence. They are furnished with a normal brain and they only need to work it right and with sufficient industry. Intelligence and industry, however, in order to lead to real success must be controlled by integrity,
Yours truly, Victor C. Vaughan.”

 

Dean Vaughan wrote this just a month after learning of the death of his oldest son, in France at the conclusion of WWI. This was also when Vaughan first considered Hugh Cabot for the chairmanship of the UMMS surgery department, and in whom the qualities of intelligence, industry, and integrity seemed to be in full display.


Five.

Opportunity. One year after this exchange of letters, when the only gender qualified for success in medicine seemed to be male, the 19th Amendment to the Constitution legislated voting rights to women. This doubled the American voting denominator and helped open up the national talent pool for work, ideas, and leadership necessary for society.

While the University of Michigan and its Medical School had been educating women since 1870 and 1871, the numbers of women in the classes, never at parity from the start, sharply dropped off in the first half of the 20th century and only reached parity in the early 21st century. The inclusion of women in medicine doubled the talent pool for medical progress.

More recently, one hopes, the George Floyd tipping point signals a groundswell of sentiment to deconstruct widespread structural racial impediments to equal opportunity for all people to pursue success.
In case you missed Randy Vince’s article, “A piece of my mind: Eradicating racial injustice in medicine,” in JAMA last month, it’s well worth reading. [JAMA, 324:451, 2020.]

 

Randy, our senior uro-oncology fellow, offers a personal perspective, referring to stages of learning in the transition from ignorance to mastery of a subject. He suggests personal steps to ameliorating social injustice, and the final one, implementation of widespread culturally-aware mentorship training, is predicated on the idea of building pipelines of opportunity for as wide a swath of the human talent pool as possible. This is a matter of widely seeking and extending mentorship throughout all communities of our potential successors. Of course, no single health care provider can mentor every possible community, but a robust team such as UM Urology can probably cover most. [Above: Vince at a socially-distanced coffee break, September 2020.]



Postscript.

Purposes and cross purposes. Higher education is in the news this month, as never before and institutions that figure out how to bring students and teachers together in safe proximity will be highly prized. Hand hygiene, face masks, and social distancing work well. It shouldn’t be rocket science to outfit some classrooms and lecture halls as “test kitchens” with vertical laminar air flow. The reversed air flow need not be “ICU grade,” but just enough to give gravity a little help with respiratory droplets. It would be money well-spent, for this will not be the last pandemic to interrupt educational routines.

Students come to colleges, universities and medical schools for a number of purposes, sometimes cross-purposes. Some want to learn who they are and understand their place in the world. Others seek knowledge and skills, or merely a ticket, to a particular occupation. Many students are deeply curious about a particular subject. No small few simply want liberation from home and opportunities for socialization. Schools, for most students, are a means to some end. G.K. Chesterton, mentioned in these columns last month, once wrote:
“ … in logic a wise man will always put the cart before the horse. That is to say, he will always put the end before the means; when he is considering the question as a whole. He does not construct a cart in order to exercise a horse. He employs a horse to draw a cart, and whatever is in the cart. In all modern reasoning there is a tendency to make the mere political beast of burden more important than the chariot of man it is meant to draw.” (Irish Impressions, 1919)

When the “end-game” is improvement of the human condition, no institution has been more durable than that of higher education in pursuing that object. From times of Socratic and Hippocratic schools to the more formalized educational center of al-Qarawiyyin in Fez (Morocco) in 859 and then Bologna’s “first” university in 1088, and present-day colleges and universities, higher education has aspired to create the citizens, ideas, occupations, and technologies of the future. In a Darwinian sense this is why they endure and grow, yet even complex multiversities, such as UM, remain imperfect in extending their opportunities fully.

We educate medical students and residents to become tomorrow’s urologists, anticipating they will be the leaders and best of urologists. The founder of UM Urology, Hugh Cabot had an even larger view as Medical School Dean, explaining this in 1925 at the 36th annual meeting of the Association of American Medical Colleges in Charleston at the Fort Sumter Hotel October 26-28. His talk “Should medical education be importantly recast?” concluded with this paragraph.
“Finally, but perhaps most important, throughout the whole period of education the goal must be kept in sight, that goal being not the successful practice of medicine but the successful service to the community. If at any point either teacher or student loses sight of service as the paramount object of the practice of medicine, then medicine will fall from its high estate and be classified, and deserve to be classified, as a trade rather than a profession.”

Those remarks anticipated comments made 35 years later on the steps of the Michigan Union by another Bostonian, Senator John F. Kennedy, in a presidential campaign speech on October 14, 1960.
“Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign. I come here tonight asking your support for this country over the next decade. Thank you.”

Hope is tempered by the blues throughout this global village in October 2020, besieged by pathogens, tribalism, extremism of all sorts, authoritarianism, economic challenges, kleptocracy, and environmental deterioration.

 

Yet, October is still a time for optimism with belief in human ingenuity to fairly share the harvest bounty and solve the problems of our times. When the talent pool for human invention is maximized by including all people, the likelihood of good solutions is increased. The short burst of autumn colors, soon ahead, is one of nature’s best antidotes to the blues before we put on winter clothes, accommodate to the gray skies of Michigan winters, and pull up comforters and quilts at night. [Above: Autumn streets, Ann Arbor 2020. Below: Halloween by Grandma Moses, 1956.]

 


Thanks for reading Matula Thoughts, October, 2020

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

 

 

 

 

     

    Seasons change

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    WN/MT September 4, 2020
    Truths & mousetraps.
    2450 words



    One.

    This September feels different. It’s no longer just a matter of seasonal daylight contraction, but also a fact of social shrinkage and much more. Summer 2020 was unlike any before and academics this autumn, from pre-school through medical school, will also be totally different. Innovation is in demand to navigate the crises in business, education, medical practice, public policy, sports, and much of everything else in daily life. The good news is that humans are good at creating new and better mousetraps, although not so good at escaping the mental mousetraps of their own follies. [Above: September ground litter, Scio Township 2018.]



    Hunkering down in the first weeks of this 2020 Covid pandemic, I reread Howard Markel’s book, When Germs Travel: Six Major Epidemics That Have Invaded America and the Fears They Have Unleashed. Written in 2004 it holds up very well now, 16 years later, offering pandemic perspective. Howard, shown above, has frequent pieces on Public Broadcasting Service (PBS), maintains the 1918 Influenza Epidemic Encyclopedia in a UM Digital Archive (chm.med.umich.edu), has a recent Medical Dispatch in the on-line New Yorker Newsletter (August 6, 2020), and a new book on genetics, called Helix, in the works.

    Lessons learned from past infectious disasters tend to be forgotten. Face-masks, hygienic measures, social distancing, and validated vaccines unquestionably mitigate transmission and acquisition of germs – medical scientists and the informed public know this much is true, but why doesn’t everyone else?

    Weaponization of those protections, particularly the ridiculously easy solutions of face masks and social distancing, as political gestures is sadly bizarre. Whether it’s a matter of ludditism, partisan ideology, or mere ignorance will be sorted out by future social critics. As a person who wore face masks in operating rooms for nearly 50 years – alongside uncounted colleagues, nurses, and scrub techs – the claims of “medical reasons” why some people “can’t wear a mask” are incredulous – as unconvincing as claims of pet snakes or birds as “medically-necessary” travel companions on airplanes. The parallel contention that the duty to wear masks violates personal freedom is certainly a far cry from anything reasonably derived from common sense or the American Constitution. It’s not surprising that similar skirmishes sprung up with the Great Influenza epidemic in 1918, when education and science had not quite universally settled the germ theory in minds, but it is astonishing to find such shenanigans a full century later. [Below: mask-wearers at University Hospitals, senior medical student Annie Minns and professors Cosmas Van De Ven and David Spahlinger – social distancing briefly waived for the photo op, Aug. 2020.]


    Two.

    Basic truths. Mousetraps for infectious diseases have come and gone, but routine hygiene and simple impediments to germ transmission (face masks & distancing) seem to be basic truths.

    Historical medical relics were facts once true for their times. The iron lung for the respiratory failure of polio was a “better mousetrap” in the 1930s through the 1950s. The original iron lung used two vacuum cleaners to change pressure in an iron chamber, compressing and inflating chests and lungs of children lying within them. Philip Drinker (1894-1972), teacher of industrial illumination and ventilation at Harvard Medical School (alongside famed UMMS graduate Alice Hamilton), came up with a popular design, the “Drinker Lung.” Haven Emerson (1906-1997), son of NYC Health Commissioner, improved the device by placing the patient in a bellows within the chamber. Emerson’s Iron Lung was quieter, lighter and only $1,000, half the price of others. It remained in production until 1970, when polio largely had disappeared from much of the planet due to vaccination. Coincidentally this is a good opportunity to refer to Markel again. [H. Markel. “The genesis of the iron lung,” Arch Pediatr Adolesc Med, 1994; 148 (11): 1174-1180.]

    Polio outbreaks were dreaded in the summer. As a child, I noticed post-polio limps in many people and heard about iron lungs, seemingly ubiquitous in every hospital. The July newsletter, Matula Thoughts, referred to our friend and colleague Skip Campbell who was hospitalized at “old” University Hospital as a youngster to treat his polio. That was just around the time polio began to disappear when field trails of Salk’s vaccine, directed from UM by Thomas Francis, proved it “safe, effective, and potent” in 1955. The Sabin vaccine soon proved better. Oddly, U.S. authorities supported only the Salk clinical trial, and Sabin had to prove his vaccine in field trials in the Soviet Union. This was no small feat in the political theater and Cold War of the 1950s, but Sabin, against the grain, organized the trials and the world ran to his better vaccine. Even now, however, global polio eradication is incomplete. [L. Roberts, Science, 367:14, 2020.]

    Situational necessity, inspiration, and competition fuel better medical mousetraps, but innovations happen best in open societies. Iron lungs were useful in their times but gave way to better innovations. Modern respiratory physiology knowledge and more sophisticated ventilatory technology sprang from other responses to polio. [J. West. “The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology,” J. Appl Physiol (2005); 99:424-432.] So once again, let’s celebrate democracy and free speech: innovation -with its validation, dissemination, and improvement – thrive best in the fertile social soil of personal freedom and open expression.


    Three.

    Mousetraps.  “If you build a better mousetrap the world will beat a path to your door.” Such is the power of “the market” at large, whether the market is commercial or intellectual. Flat Earth maps may lead some mousetrap-seekers astray, but most people find their ways to better ideas and technologies. [Above: Conventional Victor Mousetraps at Barnes Ace Hardware two for $1.69 vs. Intruder’s Better Mousetrap two for $5.99.]

    Ralph Waldo Emerson (above), the source of the phrase, actually wrote:

    “If a man has good corn or wood, or boards, or pigs, to sell, or can make better chairs or knives, crucibles or church organs, than anybody else, you will find a broad hard-beaten road to his house though it be in the woods.”

    Emerson knew something about paths in woods, not only living among them, but also hiring Henry David Thoreau as his property caretaker when the journalist of Walden Pond needed a paying job. A future tenuous connection between Emerson and Ann Arbor materialized after James Elliott Cabot (below), Emerson’s friend, executor, and biographer, fathered Hugh Cabot, who instigated the first century of Michigan Urology in 1919. “Elliott” Cabot (1821-1903, shown below), as he was known, was a brother of Dr. Samuel Cabot III and shares facial physiognomy with at least three of his sons: Michigan’s first urologist Hugh Cabot, twin brother Philip, and internist brother Richard Clark Cabot.



    Four.

    Medicine has had its share of mousetraps. Enduring diagnostic tools from antiquity  – the medical history, physical examination, rudimentary vital signs, and uroscopy (body fluid observation) – have been tested and refined in medical marketplaces over millennia. For urine inspection, pottery gave way to glass matulas, microscopes extended visual inspection into the microscopic world, chemical analysis opened up molecular composition of urine, and bacteriology led to identification of pathogens. Innovation similarly propelled stethoscopes (1816), x-rays (1896), electrocardiograms (1920s), CAT scans (1970s), and MRIs (in wide use after 2000) into the clinical marketplace. The technology of modern urology is too rich a topic for further mention here, except to take note of Nesbit’s transurethral resection of the prostate, Lapides’s clean intermittent catheterization, and McGuire’s leak point pressure.

    Amidst high-tech mousetraps of today, the simple face mask used in ORs around the world is clearly effective against dust and infectious droplets (liquid dust). A recent JAMA article by Brooks, Butler, and Redfield, suggests we implement universal masking for all healthcare workers and patients in clinical situations, affording both personal protection and source control. Aerosol particles range from sub micrometers (0.0001) to a full ten micrometers (microns) in diameter. By the way, 1000 microns equals 1 millimeter. Even simple cloth face coverings substantially limit forward dispersion of exhaled respirations in the 1-10 microgram range. [JAMA 324:635, 2020.]   [Above: ORs & face masks in Mainz, Germany. Below: airborne particles, source – Wikipedia, Particles. Horizontal axis in micrometers, or microns.] 

    A higher level of filtration than routine face masks, the N95 mask, was designed to meet the U.S. National Institute for Occupational Safety and Health (NIOSH) specification of filtering at least 95% of airborne particles. To be fully effective, it requires “fit-testing,” an annual ritual at Michigan Medicine along with the TB testing, that few knew would become so useful in these Covid times. [Below: N95 mask.]



    Some people, mainly constitutional textualists and originalists, claim that governmental agencies such as NIOSH were not “intended” by the Founding Fathers, who could hardly have known about aerosols, viruses, or the Internet. Yet the Founders surely knew that knowledge, technology, and monetary systems were changing the world and would continue to do so – Franklin, Jefferson, and Hamilton most certainly among them. Enough Founders anticipated that American governmental regulation and American free enterprise would need to work in tandem to support the foundational principles of life, liberty, pursuit of happiness, and First Amendment protections. The NIOSH agency derives from any reasonable interpretation of the Declaration of Independence and the Constitution.

    The global nature of human challenges, even for a matter so small as dust particles, is stunning. Airborne dust, solid or liquid, has no national boundaries. A NASA global simulation of aerosol transportation in the troposphere over 12 months beginning 17 August 2006, takes about two minutes to watch and will expunge any notions of national exceptionalism. This video clip shows that the recent African dust storm this year was no anomaly.
    [Title: Atmospheric Aerosol Eddies and Flows – NASA GSFC S.ogv
    Author: NASA. Date: 1 January 2008, 23:17:03]

    On the other hand, the Covid component of respiratory aerosols is fortunately not very durable in time or distance. Infectivity seems to drop off after 6 feet or some number of hours. Otherwise, the above NASA animation would be very alarming in the face of this pandemic. Furthermore, the best evidence indicates that long-range transmission of small-particle aerosols (<5 micrometers) is not the dominant mode of Covid infection. Close-range respiratory droplets (large aerosol particles >5 micrometers) is the far more likely threat, easily thwarted by face masks and a little distance. [M. Klompas et al, JAMA, 324:441, 2020.] 


    Five.

    Thermometry, a mainstay in the armamentarium of medical mousetraps, is a hot topic these days. Curiously, the fact of “normal human temperature” is not clear and some authorities believe that “normal” has been dropping. One wonders if normal temperature for communities of Inuit people living near the Arctic Circle is the same as “normal” of equatorial people, or could normal in infants be the same as for octogenarians? We don’t treat pulse or blood pressure with the same strict exactitude for all people, so why is 98.6 degrees Fahrenheit held to such precision, even though we know it’s variability in health is narrower than other physiologic parameters? Epigenetic response to modern life (industrialization, central heating, air conditioning, air pollution, global warming, etc.) surely influences the “normal” core human temperatures. Time of day, season, and age must matter as well. The site, method, and precision of measurement also effect any number obtained.

    The “normal” of 98.6 degrees Fahrenheit traces back to Carl Wunderlich (1815-1877), a German physician who questioned things (above, per Wikipedia). In 1868 he proposed 37 degrees Celsius as normal after studies using a foot-long thermometer, requiring upwards of 20 minutes to register the temperature. Surgeons may recall the term Wunderlich Syndrome, a nontraumatic surgical emergency of spontaneous retroperitoneal hemorrhage that may be caused by renal neoplasms. Mackowiak, Wasserman, and Levine in 1992, updated Wunderlich’s number. [JAMA 268:1578-80, 1992]. Newer studies suggest that “normal” human temperature has dropped by 0.59 degrees centigrade for men and 0.32 degrees centigrade for women. Urologists and zoologists know that core body temperature is a few degrees too warm for optimal testicular function in man, along with many other species, hence the “social distancing” of their placement. Evolutionary biologists may want to take note that as core body temperatures decrease, there may be no thermal reason for human testes to descend, which may severely limit the market for pediatric urologists. Kangaroos, and other creatures too, may have to adjust their testicular placement to accommodate themselves to a warmer planet (their bifid penile anatomy, caudal to the gonads, is stranger still.) [Below, Wikimedia, photographer and kangaroo unknown.]

    Crises test all creatures, from viruses to humankind, forcing epigenetic changes that allow adaptation and evolution not only of individuals, but also their societies. Homo sapiens has taken this force of nature to unprecedented levels, but just as every new era brings out innovation, each challenge uncovers new generations of Flat Earthers who retreat to comforting beliefs, dogmas, and ideologies. In the arc of human progress, truth usually wins out and each crisis finds its own necessary technologies, although the arc of progress is not smooth, but often wobbly and intermittently retrograde.


    Postscripts.

    Summer reading. Caste, The Origins of Our Discontents by Isabel Wilkerson is a timely book. The title riffs on the first two lines and pun of Shakespeare’s 1593 play, Richard III: “Now is the winter of our discontent/Made glorious summer by this sun of York.” John Steinbeck echoed this in 1961 in the title of his final novel. Coincidentally, my summer reading also included the historical novel, Hamnet by Maggie O’Farrell, that imagined the lost life of Shakespeare’s only son (1585-1596). [Below: Title page First Quatro, Richard III.]



    Caste (above) considers social and political power, but Wilkerson begins the book with “The afterlife of pathogens,” an astonishing coincidence with today’s pandemic news and world-wide political discontents. This first chapter describes a heat wave in the summer of 2016 that thawed Siberian permafrost and liberated anthrax spores from long-dead reindeer, thus causing a new epidemic in living reindeer and their indigenous herders, the Nedet people. Wilkerson then links that pathogen awakening to current political awakenings around the world.

    “The anthrax, like the reactivation of the human pathogens of hatred and tribalism in this evolving century, had never died. It lay in wait, sleeping, until extreme circumstances brought it to the surface and back to life.”


    Coincidences. G.K. Chesterton (1874-1936), English writer and author of the Father Brown priest-detective books, called coincidences spiritual puns. A less spiritual person than Chesterton might call coincidences cosmic puns or stochastic puns, but the idea is the same: unrelated but concurrent events or facts may seem to have been “divinely ordered” or happen “by the luck of the draw.” Chesterton’s actual quote comes from his book, Irish Impressions, in 1919, a year that coincides with the start of the first century of urology at the University of Michigan:

     “All literary style, especially national style, is made up of such coincidences; which are a spiritual sort of puns. That is why style is untranslatable; because it is possible to render the meaning, but not the double meaning.”

    Considering this first half of 2020, random chance is due to favor better luck in pathogens.

    Thanks for reading Matula Thoughts this Labor Day, 2020.
    Best wishes,
    David A. Bloom

    Flat vs. round

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    WN/MT June 2020

    Flat vs. round.

    2949 words

    [Blue Marble from NASA Terra at 438 miles.]

    Last month, world attention was dominated by a disruptive virus, angered by ugly politics, briefly turned to a space station special delivery, and horrified by the retrograde murder of George Floyd. Michigan Urology also lost one of its foundational alumni, Ed Tank.

     

    One.

    A flat Earth was a reasonable belief for Homo erectus and their other hominin cousins, including Australopithecus sediba shown below in reconstruction at the University of Michigan Natural History Museum (visited just prior to the closure for coronavirus). The campfires, hunting grounds, and cave dwellings of early humans reinforced a sense that their environments were mainly two-dimensional landscapes of hills, valleys, and forests.

    That mind-set changed when clever Homo sapiens, sailing the seas and studying the skies, figured out the true fact of the round Earth: sailors noticed mountain peaks well before they saw the shorelines as they approached land and astronomers, lucky enough to see eclipses, deduced that circular shadows on the moon could come from spherical bodies. Aristotle captured some of these ideas in writing and a few intrepid navigators had enough faith in a round Earth hypothesis to venture west across the Atlantic, millennia later. [Below: lunar eclipse, Wikimedia, with permission, Tom Ruen 14 October, 2014.]

    John Cabot in 1497 was one of the first identified Europeans to navigate to the North American Continent. Unnamed Norse explorers and fishermen as far away as the Basque region fished the Grand Banks seas and set foot in present-day Newfoundland and Labrador centuries earlier, but it was John Cabot from Bristol, England, to whom the first name can be attached. Originally named Giovanni Caboto from Genoa, he worked his way to Venice, then Spain, and finally England seeking funding for an expedition. Bristol, the second largest city in England and a major port, was where he raised enough capital to build a three-mast ship of 60-feet and 50 tons and find a crew to follow his belief in a round Earth. King Henry VII gave Cabot a Royal Warrant (a “visa” of the time) to explore what was presumed to be Asia. Cabot’s single ship crossed the rough North Atlantic with a crew of 18-19 in 34 days, explored Newfoundland or Labrador, and accurately returned to Bristol in 15 days.  The journey was repeated successfully once, but the ship was lost in 1498 on a third try. [Below: traditional globe.]

    Five years before Cabot’s journey, another immigrant from Genoa, then living in Spain, crossed the gentler southern Atlantic Ocean to Caribbean Islands with three ships. Christopher Columbus had obtained financing from King Ferdinand and Queen Isabella, making two other return trips, but never reached the mainland. In fact, no one from the Spanish contingent reached the actual North American continent until 1513. It is possible that Columbus and Cabot met in Spain between 1490 and 1494, but Cabot certainly knew about the travels of his fellow countryman. Columbus and his sons branded their enduring legacy effectively. Cabot, lost at sea on his third voyage, wasn’t so well represented by his son Sebastian who was more interested in his own opportunities than advertising his father’s accomplishments. The Cabot story was eclipsed until now. Was Giovanni Caboto an ancestor of Hugh Cabot? It’s quite possible.

     

    Two.

    Retrograde visions. Orlando Ferguson (1846-1911), a self-styled professor from Hot Springs, South Dakota, copyrighted his Map of the Square and Stationary Earth in 1893, subtitled “Four Hundred Passages in the Bible that Condemns the Globe Theory, or the Flying Earth, and None Sustains It.” He completely discounted two and a half millennia of recorded human history and verifiable knowledge in favor of his literal translation of the Bible and belief in a “square and stationary Earth.”

    Born near Du Quoin, Illinois, Ferguson moved to Dakota Territory in the 1880s, opening a grocery store and hotel. After a fire destroyed the hotel, he built a bath house near Siloam Springs and became known as “doctor” to some patrons. Fergusson’s map never gained traction and fell out of sight until discovery more than a century later. The map was donated in 2011 to the Library of Congress by State Senator Don Homuth. [N. Jackson. Library of Congress Receives Rare Map depicting Earth as Flat. The Atlantic, June 22, 2011.]

    Edwin Abbott Abbott (1838-1926; shown above, Wikipedia), English schoolmaster and clever satirist, poked fun at his stultifying Victorian culture with a book in 1884 called Flatland: A Romance of Many Dimensions. Perhaps not wanting to be identified too closely to the ancient idea, Abbot used the pseudonym “A Square.” One of its illustrations (below) may have served as a model for the gendered entrances to the original Michigan Union, when it was built in 1917.

    One of Abbott’s students at the City of London School, Herbert Henry Asquith, became Prime Minister of the United Kingdom from 1908 to 1916. Later the Earl of Oxford, Asquith, didn’t take Abbott’s Flatland literally when he oversaw the dispatch of the British Expeditionary Force (BEF) to the Western Front in The Great War in 1914. (Hugh Cabot would join the BEF in 1916.) The Flatland story was picked up in a 2007 film and two shorter films, Flatland: The Movie (2007) and Flatland 2: Sphereland (2012). Abbott’s “romance” was a clever fantasy and is still an entertaining read (below), but The Flat Earth Society is a meme for people unfortunately stuck in obsolete versions of reality or obstinately clinging to it for self-serving reasons.

     

    Three.

    Hardy Hendren, an iconic presence in my clinical education and even more so for that of John Park, introduced me to the Flat Earth meme, once commenting: “If you stick around long enough, you’ll meet someone who believes the world is flat.” It was a good lesson and I didn’t have to wait long to find members of the Flat Earth Society. Hendren was one of the best early explorers of the round earth of pediatric urology, but warned his students that Flat Earther’s always try to block progress. [Above: Hendren as visiting professor at University of Michigan 2012.]  Luddite is closely synonymous for the frame of mind in which persuasive argument, careful observation and reasoning, or scientific evidence fail to release a person from primitive beliefs.

    Hardy educated his trainees in many ways even outside the operating room, where his rigor of thought, innovation, and tenacity were unmatched and those disciples carried his ideas and philosophy around the world.

    Hendren’s clinics, relationships to referring physicians, and care for his supporting team set powerful examples for generations of students, residents, and fellows. After his own diagnosis of colon cancer, publicly discussed for all to learn from, Hardy quit smoking and became evangelical in urging those he encountered to quit. Trainees, colleagues, and people on the street were lectured vigorously. So too were parents of the children he treated – I marveled at his bravery, holding out a trash can to astonished parents in clinic to dispose of their cigarettes and lighters. Some may have seen this as an affront to personal choices, but Hardy was on a mission to minimize comorbidities of his patients, dispelling Flat Earth views of the world, including that of the healthy cigarette. Alberto Pena, Mike Mitchell, Rick Rink, John Park, Joe Borer, David Joseph, and Craig Peters with so many others took notice and found their own ways to perpetuate Hardy’s work in their practices and carry his ideas around the world. (Below: modern version of Cabot’s journey.)

     

    Four.

    Debts of gratitude. Almost everyone I know in health care proudly carries debts to influential teachers and role models. While the term, debt of gratitude, raises eyebrows of grammatical purists it does seem to work for most of the rest of us, especially in terms of our mentors and role models. Hardy Hendren stands tall in my list. Although I didn’t train with Jack Lapides, only knowing him in his retirement years, Jack, too, is high on the list for the contributions he made to our field and his style of intellectual rigor was impressed on his trainees and disseminated throughout their careers to their own students and colleagues such as myself. I have heard Jack mentioned with reverence over the years by so many of those who came within his orbit including Bill Baum, Marc Taub, John Hall, Barry Kogan, Steve Koff, Evan Kass, Bart Grossman, Gary Wedemeyer, Jay Hollander, and Ed Tank to name just a few. Our role models, and so much more of what is good in humanity, get drowned out by the daily tragedies and evils that compel our attention to news cycles.

    Last week’s UMMG Town Hall responded mainly to the covid disruption of our work and lives and something David Spahlinger said caught my attention. He offered the metaphor that in the present phase of our national and personal traumas many people are in the “valley of disillusionment.” In our UM health system David is in the tough position of being the daily lightning rod for complaints, anger, disillusionments, and expectations for solutions to extremely difficult problems. Yet as an internist and intensivist, working in the thick of things and as president of the health system making rounds throughout all corners of the medical center, he is eminently credible. His talk noted that some of our colleagues “bristle” when they are told that “we are all in this together,” because the reality is that the suffering is inequitable. People suffer in very different ways – from the front line maintenance worker to the ICU nurse to the junior emergency department resident to the exhausted hospitalist to the beleaguered phone line staffer to the senior administrator trying to do their jobs. Each person’s home and family situation is unique and it is perhaps presumptive when leaders presume cohesion of a group. Spahlinger wisely said:

    “The financial impacts of no merit increase and suspension of retirement contribution are not felt equally by everyone. Likewise, not everyone is working on the front line risking their own health. Those at home are under stress as they wonder if they have a job to come back to. My point is that everyone is suffering in different ways. The reason I say we are all in this together is that I don’t think we can prevail as an organization and carry out our mission unless we face the challenges ahead together.”

    From my point of view as a colleague of David Spahlinger over the past 30 years, we all owe a great debt of gratitude for his excellence as a clinician and credible leader in our health system.

     

    Five. 

    Ed Tank. Michigan Urology lost one of its most extraordinary alumni when Ed died in Portland, Oregon on May 13 at age 88, leaving his wife Rosalie, four children, seven grandchildren, and a three-year old great-grandson. Born on March 23, 1932 in New Rochelle, NY as the first of two children, Ed grew up in the midst of the depression admixed with the urban excitement of his region. As a young boy he recalled meeting the legendary Yankee baseball player, Lou Gehrig (1903-1941) in an elevator. The Tanks moved to Western Springs, Illinois, in the Chicago area sometime around 1938 and Ed attended public schools in the La Grange district. The east drew him back for college at Amherst where he dove deeply and enthusiastically into liberal arts, in addition to having an outstanding collegiate wrestling career. In college he fell in love with Dixieland Jazz and loved to travel to Jimmy Ryan’s Jazz Club on Manhattan’s West Side to hear Wilbur de Paris and his band.

    Medicine attracted Ed late in his college years and after graduating in 1954, he returned to Chicago for a postbaccalaureate year at Loyola to fulfill medical school requirements. This got him into St. Louis University Medical School, graduating in 1959. Along the way on a road trip back to Amherst for his third year college reunion Ed reacquainted with a childhood friend, Rosalie Butterfield, in Philadelphia and the couple married six months later. In St. Louis the couple had their first child while Ed was coincidentally rotating on the obstetrics service where Rosalie gave birth to Ellyn Marie.

    In July 1959 Ed began surgical internship and residency at the University of Michigan under Gardner Child, III. The couple remained in Ann Arbor for two additional years, living quite happily as Rosalie recalls living in converted wartime housing then still present in Pittsfield Village and growing their family, with Julie who was born at St. Joe’s.

    A research year was necessary in the surgery program, unless a resident had served in the military – and if so they were forgiven the year. Ed chose to do his research in Boston 1962-1963, working closely with Bill Bernard on hyperbaric medicine and was inspired to pursue pediatric surgery. A third daughter, Katie, was born at Boston Lying-In Hospital.

    The Tanks returned to Ann Arbor in the summer of 1963 through summer of 1965, as Ed completed his surgery training under Gardener Child and during Reed Nesbit’s last years of leadership in urology. In July 1964 their son Ted was born at University Hospital.

    Ed took the family back to Boston at Children’s Hospital for two years of training under Robert Gross, whom Rosalie recalls more of “a name” rather than a strong influence in Ed’s training at that time. She recalls Arnold Colodny’s strong influence then and Ed’s “double dose” of pediatric urology rotations under Alan Perlmutter.

    In the summer of 1968 Ed returned to the University of Michigan as its first pediatric surgeon, but encountered turf issues with other surgical disciplines, distrustful of the emergence of pediatric surgery as a discipline. Thoracic surgeons were unwilling to “relinquish” the chest to Ed. Jack Lapides, Michigan’s new chief of urology, offered additional training in the urology domain and Ed, therefore, spent two years as a urology “resident” under Lapides while still holding responsibilities as a faculty member. Ed Tank then became the first trained pediatric urologist at the University of Michigan and remained on the faculty until May 1973 when he took a job in Portland at Oregon Health and Science University. The University of Michigan then had no pediatric surgeon until Arnie Coran came in July 1974.

    Portland had been selected after a “big family discussion,” according to Rosalie. Ed enjoyed his work there with Jack Campbell, but found he had to focus on pediatric urology exclusively, even though he had hoped to practice general pediatric surgery as well. Ed was a superb clinician, surgeon, and teacher and inspired a generation of students and residents, one of the earliest being Rob Kay who came from UCLA medical school to Portland for residency 1974-1979, before going to the Cleveland Clinic. Ed’s first associate in pediatric urology was Steve Skoog who came in 1992, having trained at Walter Reed Army Medical Center and the Washington National Children’s Hospital under Barry Belman in 1985-1986. Steve recalls his first case with Ed was a 7-year old with Mayer-Rokitansky syndrome who had a Young-Dees urethroplasty and bilateral reimplantation.

    Ed, wanting to cut back somewhat clinically, left the university in the mid-1990s and joined the Northwest Urologic Practice with Tom Pitre, operating at Emanuel Hospital.

    Ed was leader in pediatric urology nationally, serving as Chair of the Section on Urology of the American Academy of Pediatrics 1990-1991. Some of his papers stand as “classic” in pediatric urology literature. Ed loved the Northwest and continued his boyhood love of fishing. He and Rosalie explored the round earth from Alaska to Antarctica. Ed was a big reader – always carrying a serious (nonfiction!) book with him. Rosalie recalls that she couldn’t talk him out of lugging a large hardcover biography of Truman or Eisenhower with them as they trekked the Himalayas.

    Ed and Rosalie then focused most of their time in Sunriver Oregon and on their grandchildren, but continued some work for a time at Madigan Army Hospital and Native Health in Alaska before it had regular coverage. His collegiate passion for Dixieland Jazz persisted throughout his life and he made Rosalie a convert to it, with “umpteen jazz trips” across the country and around the world.

    Ed and Rosalie loved and supported local classical music and repertory theater. Ed was a cheerful and generous maverick and always a passionate teacher, whether the subject was pediatric surgery, fish anatomy, crabbing, or subjects of his wide-ranging reading. Ed Tank was the first bona fide pediatric surgeon and pediatric urologist at the University of Michigan – a wonderful physician, teacher, role model, and friend to those lucky to have known him.

    [Below: the subtle arc of the horizon from Portland to Detroit on a Delta Airlines Boeing 737 five miles high.]

     

    Postscript.

    On this round and small Earth, everything and everyone is connected. Events and ideas that originate at one spot may reverberate widely and persistently around the sphere. Navigation of the round Earth was not universally beneficial, certainly not for indigenous peoples of the Americas, Australians, or enslaved Africans.

    David Spahlinger’s point, quoted above, links a number of issues at this distressing moment in time, including our rattled workplaces at the University of Michigan and the death of George Floyd on a Minneapolis street. I took from David’s statement at the Town Hall, that a legitimate understanding of the diversity of suffering predicates any solution to any particular challenges of the moment (and any claim to unity, i.e. “we are all in this together”). This applies beyond UM to regional, national, and global predicaments of poverty, war, and human justice. If individuals of diverse perspectives and circumstances are to find solutions to existential problems, any effective leadership for them must be credible –  credibility built not only on respect for diversity but also commitment to fair amelioration of inequities as we rebuild from months of the covid economic crisis and centuries of retrograde human inhumanity.

     

    Thanks for reading Matula Thoughts, this June, 2020.

    David A. Bloom

    University of Michigan

    Back on the road to contagious hospitals

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    Matula Thoughts 1 May 2020
    2430 words


    Back on the road to contagious hospitals

    “Reading gives us someplace to go when we have to stay where we are.”
    Mason Cooley, American aphorist, 1927-2002.


    [UH & UMMS Early spring 2020 on the road from old AA train station to main campus of Michigan Medicine.]

    One.

    Back on the road. May is usually a sweet spot in the calendar, but not so sweet around the world this year. Some random mistakes in the RNA sequences of a single common virus created a new version that has wrecked worldwide havoc on health, hospitals, and economies. Normally in May, memories and anticipations run strong, for it is a particularly sensual time of the year when colors, smells, tastes, sounds, seem to have especially bright notes after winter dormancy has lifted in the northern hemisphere. That sense of memory and anticipation is reflected in William Carlos Williams’s curious piece, Spring and All [By the road to the contagious hospital], written by the New Jersey physician and published in 1923. The title has long intrigued me and the content continues to puzzle me. Williams was a doctor in New Jersey, who wrote in his spare time. He was an excellent physician, my friend Joan Chiaviello Flanigan recalls from his care for her family when she was a child.

    The odd free verse poem of Williams is deliberately mal-organized into 27 sections (identified by Roman enumeration I through XXVII, minus the missing number VII), with random prose interludes of commentary, “chapters,” and unidentified “footnotes” interspersed throughout it. An upside-down Chapter XIII follows a normally-oriented Chapter 19 in the unspecified introduction to the poem. Most verbal images precede spring and are neither attractive or cheering. Spring and All, both poem and its world, is very much upside down and disordered, until XXII and the Red Wheel Barrow that helps set things right. [Below: the confusing “Chapter XIII.”]

     

    Little did we expect, just a year ago writing here about Williams, that we would actually be back on the road to contagious hospitals this May in 2020. Luckily, the Michigan Medicine field hospital at the athletic complex did not require deployment several weeks ago because social distancing and personal hygiene flattened our covid19 curve enough to preclude the new contagious hospital in Ann Arbor – at least for now. Given the widely disseminated knowledge of historians and scientists, it is incredible that we were surprised (again) by a terrible infectious pandemic.

    Two.

    Contagious diseases worried the University of Michigan Medical School in 1897 when it converted a small laundry shack behind the Homeopathic Hospital into a Contagious Ward for diphtheria, smallpox, and scarlet fever, diseases barely mentioned in medical schools today. In 1914 the city of Ann Arbor, still recalling a 1908 smallpox epidemic, gave the university $25,000 for a new Contagious Disease Hospital with 24-beds in an isolated area, well to the east of the larger hospital grouping. The civic contribution was as much a matter of self-protection than generous philanthropy, although the two attitudes are not unrelated, for philanthropy after all is a self-protective attribute of humanity at the species level. [Below: Michigan’s Contagious Hospital 100 years ago. Bentley Library.]

    Williams wrote Spring and All [By the road to the contagious hospital] at an exuberant time for the University of Michigan and its Medical School. Urologist Hugh Cabot, recently appointed dean (in 1921), was building a great medical faculty and new hospital. Michigan’s  contagious hospital of that time is now long gone and the idea of contagious hospitals had all but disappeared in Ann Arbor and around the world, until this past winter. Some modern hospitals, such as our new Mott Children’s Hospital have been built for contingencies of terrible new epidemic possibilities such as SARS and Ebola, as well as resurgences of ancient ones like measles – perplexing and only understandable because of persistent human folly. Contagious hospitals revived in Wuhan and Manhattan this winter, although they seem to be more contagious dormitories rather than hospitals as we now think of them.

    Three.

    A May birthday. One birthday to recall this month is that of Dorothy Mary Crowfoot Hodgkin, born on 12 May 1910 in Cairo, Egypt. I first became interested in Hodgkin when I saw a painting of her at the National Portrait Museum in London, last winter during a visit for the wedding of the daughter of my good friends from our training years in London, Robert and Anita Morgan. The painting was prominently displayed and instantly attractive, but a mistake in the label next to it caught my attention.

    Dorothy was the oldest of three daughters of John Winter Crowfoot, a civil servant in the Ministry of Education, and his wife Grace Mary Hood. Living and working in Egypt for many years, the family returned to their native England each summer in the hot months and during one of those summers WWI began. In that August of 1914 the parents left their girls with paternal grandparents near Worthing to return to Egypt, where father could continue work.

    After the war, the reunited Crowfoots relocated to Sudan where Mr. Crowfoot was put in charge of national education and archeology, until 1926. The girls attended local schools in Sudan and Dorothy became fascinated by archeology and the mosaic tiles in Byzantine-era churches. She also developed an interest in chemistry and her mother, a botanist, gave her a book on x-ray crystallography for her 16th birthday. Dorothy combined her interests by drawing pictures of mosaic patterns and doing chemical analyses of the tile cubes, called tessera. At age 18 she returned to England to study chemistry at Somerville College, Oxford, and received first-class honors in 1932, proceeding then to Newnham College, Cambridge for Ph.D. studies.

    Dorothy worked with John Desmond Bernal on applications of x-ray crystallography to protein analytics and their work on the structure of pepsin turned out to be the first biological crystallographic analysis. Dorothy obtained her Ph.D. in 1937 for work on sterol structure and she held a post as Oxford’s first fellow and tutor in chemistry until 1977. In 1964 Hodgkin won the Nobel Prize in Chemistry. [Below: Hodgkin’s model of penicillin. Science Museum London, Science and Society Picture Library.]

    Molecular model of Penicillin by Dorothy Hodgkin, c.1945.

    One of her students, a young woman named Margaret Roberts at Oxford from 1943 through 1947, wrote a dissertation on the x-ray diffraction of the antibiotic gramicidin that led to a good job in industrial chemistry but Roberts turned to politics around 1950, married Dennis Thatcher in 1951, and qualified as a barrister in 1953. In 1959, then Margaret Thatcher, she was elected member of Parliament, rising to Prime Minister in 1979. In her office at 10 Downing Street Thatcher displayed a portrait of her former teacher. Hodgkin, however, was a life-long supporter of the Labour Party. [Below: Hodgkin legend with corrected name of artist. National Portrait Gallery London, December, 2019.]


    The mistake that caught my eye at the National Portrait Gallery was in the adjacent description of painting and artist, Maggi Hambling, where her first name was written “Maggie,” but someone (I’d imagined it might have been the offended artist herself) crossed out the final “e” with what seemed to be a pencil. No matter, the museum is now closed down for a lengthy renovation and time will likely heal this minor error.

    Four.

    Among the many innovative changes Ganesh Palapattu has brought to the Department of Urology is the broadening of the weekly grand rounds conferences to periodic wider learning experiences that extend beyond world of urology, that he calls “Teach us something.” A session of this nature in late February featured Professor James Kibbie, Chair of the University of Michigan Organ Department who taught us something in the School of Public Health (SPH) where one of the 16 pipe organs of the University of Michigan temporarily resides. In late February Professor Kibbie spoke on “Bach and the Organ,” and treated our faculty and residents to three beautiful pieces (played on the James Walgreen Létourneau Organ on loan to the SPH) from the 270 surviving organ compositions of Bach. [Above: Professor Kibbie at urology grand rounds.]

    Kibbie has been collaborating with computational faculty to understand the science behind Bach’s music and a recent grant from Barbara Sloat allowed him to record all of the Bach organ works, all 270 pieces, performing them on instruments of Bach’s era located mainly in Germany. These works are available to the public through the University of Michigan. [From Prof. Kibbie: “If you want to add the URL for the university’s website with the free downloads of my Bach recordings, it’s http://www.blockmrecords.org/bach.”%5D


    [Above: Kibbie, Vesna Ivanĉić, Sam Kaffenberger.]
    The pipe organ, complex and large, manipulates forced air through many ingenious pipes. Mistakes are inevitable in all spontaneous performances and Professor Kibbie explained how organ recitals are particularly susceptible, having three keyboards, multiple stops, layers of foot pedals, hundreds or more pipes, and up to 100,000 parts. Paired with the human factor, pipe organs offer countless opportunities for performance variations and transcription errors. Of course, Professor Kibbie’s ear can register musical mistakes that fly by most of us with untrained attention.

    Everyone makes mistakes from the moment they arise in the morning, whether squeezing out too much or too little toothpaste, rolling through a stop sign on the way to work, or parking too close to an adjacent car – the possibilities are myriad although most are inconsequential. Error is something we understand in clinical work. Medical mistakes may be transcribing errors when writing (now, typing) patient stories, missing veins on blood draws, or making erroneous clinical decisions. To err is human, to err consequentially is unfortunate.

    Algorithms promise perfection, if we are naïve enough to forget that they are written by humans. Whereas a piano played spontaneously offers novel idiosyncratic momentary interpretations, innovations, or mistakes that combine to make each performance unique – and mistakes are nearly inevitable –  a programmed piano (player piano) is free of performance interpretation and variation. The standardization (assumed to be error-free, but any algorithm is only as good as its author) brings freedom from the anxiety and art of human performance.



    Five.

    A scarlet tanager showed up in our old neighborhood last May around this time. My neighbor, Mike Hommel, called to alert me one Friday afternoon when I was indoors on the computer working on the Urology Department history. Mike is a great naturalist who can spot morels on the ground and birds in the trees better than anyone I know and that day, specifically 10 May 2019, he spotted this little fellow, tired and resting after a long flight from somewhere in the south. The splash of color is amazing and has served its evolutionary purposes well. This little guy was not too concerned by our attention as it shifted trees periodically and hopped to the ground to feed from time-to-time.

    Had William Carlos Williams spotted a scarlet tanager on his road to the contagious hospital, the poem would probably have been much different. (Such are the contingencies of life.) Piranga olivacea used to be categorized in the bird family Thraupidae within the Passeriformes family (the perching birds with one backward and three forward toes) but DNA studies have reclassified them to the cardinal family (Cardinalidae). When I was younger the Linnaean binomial classification held little interest for me, but my perspective has changed. I looked for the tanager the next day, but he had moved on. A number of deer, however inspected me carefully. They used to drive us crazy, eating everything we planted, and either we would shoo them away or our dog, Molly, would give chase. By May, 2019, Molly’s arthritis had erased her interest defending the property and at that point the property seemed to belong more to the deer than to Molly or us, which was just as well for we had sold the house to downsize in downtown Ann Arbor.

    Other hopeful signs of spring popped up last month, oblivious of the prevailing RNA threat to humans. [Above and below: early April 2020, Ann Arbor Water Hill area.]

    [Above: pond in West Park. Below: new normal – outdoor picnic tables at Zingerman’s replaced by spaced waiting areas for take-out orders.]

     


    Postscript.

    Disruption. Is clinical medicine a performance art, as aspired to by professionals since Hippocratic times, or is it becoming an algorithmic practice? Professor Kibbie provoked this question. The doctor-patient relationship has been disrupted by the “encounter” framed by the electronic health record (EHR) format, that is the ubiquitous EHR-directed patient “encounters” have replaced the narratives my generation was taught to elicit. We used to initiate evaluation of patients using the so-called SOAP notes (subjective, objective, assessment, and plan) that align with the medical gaze – Sherlockian/Oslerian scrutiny by a trained observer. 

    A “chief complaint” was a story that could be boiled down to a phrase, but narrative demanded more and gave the chief complaint context. Shoulder pain could be a malignant metastasis or a rotator cuff injury and it was important to know if the injury was life-style related, due to occupation, or traumatic; the story behind the pain, its comorbidities and social determinants, are no less relevant than the pain itself. Abstraction of a patient’s story to a drop-down phrase or an ICD-10 numeric diagnostic code is a poor substitute for conversation, medical gaze, and narrative. We should resist this terrible trend as best we can and create EHRs that support narrative inquiry and medical gaze rather than commoditize encounters.

    One hundred years ago, Hugh Cabot got off the train from Boston at the old Ann Arbor station (shown at the top) and initiated the first century of Michigan Urology, not knowing that he would have little more than a decade to do it. Medical care had its disrupters back then, new technology, burgeoning subspecialties, and novel models of practice. Some tension existed between the old and the new approach to disease. Classical Oslerian ideas are routed in the bedside medical gaze and dialogue with the patient to understand and explain the problem. The new scientific approach sought to understand disease based on facts derived in research laboratories, other sources of verifiable data, or from the patient as a virtual laboratory. Clever clinicians recognize it is not a matter of one or the other, patients deserve both approaches. Brutal realities of a post-covid19 world will favor the curt, transactional, commodity aspects of health care. Role models in fiction and fact such as Sherlock Holmes and William Osler, and new analyses such as The Good Doctor – Why Medical Uncertainty Matters, a book out soon by Kenneth Brigham and Michael Johns, help navigate this new era of disruption.

    [Below: sign of spring, late April, near Barton Pond.]



    Thanks for reading Matula Thoughts of May, 2020.
    David A. Bloom, University of Michigan Department of Urology

    April, perhaps the cruelest month

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    WN/MT 3 April 2020
    2356 words

    This April, perhaps the cruelest month



    One.

    April, was the original title of this painting by American impressionist Frederick Childe Hassam, a century ago, in 1920. It was an optimistic time when the world was rebounding from years when the thin veneer of civilization seemed to be wearing away with war and influenza. The pendulum of events changed for the better and, in Ann Arbor, Hugh Cabot started up a century of modern urology at the University of Michigan.

    It is a mystery what drove Hassam, just then, to go back to his very beginnings with this work. Maybe the emergence of the world from the edge of catastrophe just then was a factor. He renamed his painting, Green Gown, the woman in green being Rosa Delia Hawthorne, Hassam’s mother, depicted in an April a half century earlier when three months pregnant with Frederick (born October 17, 1859 in the family home in Dorchester, Massachusetts). [Above: April, Courtesy, Gibbes Art Museum.] The gorgeous composition shows Hassam’s imagination of his mother at 27 years of age, reclining pensively on a settee, as if considering her next 6 months of confinement or the joys and trials of parenthood. A daffodil arrangement in the right foreground reinforces the time of year in the original title. Yet it was an odd concept for a painting, with the artist picturing his mother in the first trimester of pregnancy with him, at his actual beginning. This was a curious contrast to Whistler’s famous consideration of his own much older mother a half century earlier.

    Hassam’s painting is a suitable introduction to April, the beginning of spring in the northern hemisphere, when showers anticipate May flowers, as the saying goes. Another painting by Hassam, The Avenue in the Rain (in the White House Collection) depicts Fifth Avenue in NY around the time of WWI and perhaps during some April showers. This was one of 30 paintings in Hassam’s Flag Series.



    Hassam purchased a home in 1919 in East Hampton where he most likely painted April the following year and would live another 15 years, dying in East Hampton at a respectable 75. The country was in a patriotic mood in April, 1920, with the Great War and recent influenza epidemic no longer existential threats, but the national optimism eclipsed any prudent attention and resources to prepare for the next iterations of existential threats. This April, normally a time for beginnings, existential threats are back at civilization’s door. [Above: The Avenue in the Rain. Hassam, 1917. White House Collection, since the Kennedy Administration. Below: Oval Office 2009, photo by Pete Souza with the president and the picture on the wall.]





    Two.

    A century is a convenient milestone, although most humans fall short of this in their life spans. The modern average of “three score and ten” or so, however, is ample time to leave something behind, if one is fortunate, in good works, successors, and kindness. Octogenarians, septuagenarians, and centenarians are rarities, the products of good genes and lucky circumstances. The U.S has 80,000 centenarians, the U.N. estimates 343,000 worldwide in 2012 and projects 3.2 million by 2050.

    A century is an extreme stretch for a single human, few make it that long, but human collectives – nations, organizations, corporations, and other teams – are not limited biologically and for them a century is a useful ruler to measure accomplishments and create historical narratives. So, consider medical practice and urology in April 1920, in particular, when the grim experiences of war and influenza were fading from memory, although some lessons learned were working their way into civilian health care. The growing scientific knowledge base of medicine and its burgeoning subspecialties by 1920 had rendered medical school alone insufficient training for the new generation of medical practitioners; internships and residency programs were producing a new world of graduate medical education that became the career-defining element of medical training.

    This centennial year of urology at the University of Michigan is an opportunity to understand our organizational corporate past and some of the many stories relevant to Michigan Urology. Additionally, the centennial is a chance to personally reconcile with our roots in healthcare and at the University.

    With the present world turned upside down by Covid19, the AUA in Washington, DC and Sunday Nesbit reception are cancelled, but we look forward to the autumn and September 24-26 with the Nesbit alumni reunion here in Ann Arbor, featuring guest speaker alumni Carol Bennett, Barry Kogan, Ananias Diokno, Carl Smith, Curtis Nickel, Mitch Albom, and Sherman Silber, among others. The first of our two books on Michigan Urology will soon be available (and also online via Michigan Publishing), this being Urology at Michigan – The Origin Story, tracing the development of genitourinary surgery, the University of Michigan, its Medical School, and the introduction of modern urology to Ann Arbor by Hugh Cabot. Book two will cover the first hundred years of urology at Michigan, year by year, expanding on the Konnak and Pardanani text that Jim Montie commissioned 20 years ago. We hope to finish this in the next year.

    This April 2020 it’s natural to pause for a moment and consider what urology practice and education were like 100 years ago. Cystoscopy, a new skill of the late 19th century, required special instruments and novel expertise that defined urology and fueled its early creative burst. A new breed of surgeons picked up cystoscopy, improved the technology, gained insight into genitourinary dysfunction, and created miracles of minimally-invasive therapy. Nonoperative and open solutions to urinary problems expanded urology, after it was so-named in 1902. Urology came together as an open organization in 1910, created rational training programs for young physicians, and formed its own journal in 1917. Little of this progress translated to the battlefields of WWI, but the civilian progress accelerated after its conclusion, although barely in time to be applied in the next war.


    Three. 

     

    In April, 1920, the Cabots were adjusting to their new lives in Ann Arbor. Hugh was busy as chair of the Surgery Department and the sole urologist at the University of Michigan. Cabot’s two competitors in Ann Arbor, still calling themselves genitourinary surgeons, had left the university to practice a few blocks away at St. Joseph’s Mercy Hospital and neither they nor Cabot had any interest in collegial relationship. The University Hospital complex was physically constrained and outdated, pale in comparison to the facilities Cabot left behind in Boston, but a quantum leap from the 2,500-bed hospital he had commanded in France on the Western Front of the Great War.

    The Cabot family was living temporarily in the President’s House, having cajoled the Regents into its use pending the anticipated summer arrival of incoming President Burton. Anxiety was growing within the university administration as it tried to coordinate renovations demanded by the Burtons and uncertainty over the Cabot’s plans. At work, Cabot had to manage the teaching and clinical responsibilities of his small Surgery Department, deploying the full-time compensation model. To grow his small and inbred Surgery Department Cabot leveraged his military connections to bring two essential additions to Michigan that year, Frederick Coller and John Alexander.


    Four.

    Just about halfway between the start of the Michigan Urology centenary and now, I began my era of training. It was 1971 and urology was at a watershed. It sat between an era of board-certified urologists with life-long certification working in individual or small practices and the present era of urologists with contingent re-certification working in large practices or multispecialty health systems. In 1971 fiberoptic cystoscopy had only recently replaced first generation cystoscopes, illuminated by distal mignon lamps of Edisonian technology; transurethral surgery was one of surgery’s rare minimally-invasive operative procedures; major open reconstructive urologic procedures were available at only a few centers; the intravenous pyelogram and retrograde injection studies were the main imaging modalities (ultrasonography was in its primitive stages); and training programs were mostly small and weakly standardized. That year, Jack Lapides Section Head of Michigan Urology from 1968 through 1983, introduced his strongly disparaged idea of clean intermittent catheterization.

    Meaningful visual cystoscopic acuity for old-time urologists required much skill, art, and experience. For learners, peeping over the shoulder of  cystoscopists (whenever they decided to let learners have a look), the opportunity was fleeting. This scenario earned Jack Lapides his covert nickname, Black Jack: for he was known to temporarily disconnect the light cord (by stealth of hand) before letting the learner look through the scope and asking what they saw. [Below, Jack Lapides photo by DAB.]



    Lapides had been a loyal and productive lieutenant to Reed Nesbit for some 20 years. When Reed was aiming toward retirement in 1967, Jack no doubt felt inclined to take over the leadership of the small section. The two urologists seemed to have gotten along well professionally, although there was no doubt as to who was in charge and it didn’t seem that a strong friendship existed outside the workplace. Lapides had been running his own separate and independent residency program at Wayne County Hospital, graduating a single chief each year whereas at this point the UM program was finishing 2-3 per year.

    Karl Montague (UMMS 1968), visited by us last autumn at the Cleveland Clinic, recalled his experience as a junior medical student rotating on urology. Karl had been focused on a career in cardiology, primed in that direction by an NIH fellowship in Basel, Switzerland. Urology at the University of Michigan was then a mandatory clinical rotation and Montague recalls some of Lapides’ pedagogical antics (at the VA):

    “Dr. Lapides was demonstrating cystoscopy to a group of us medical students in our third year. Of course, this was before the time of video teaching and the learner had to peer over the shoulder of the teacher who had positioned the scope over a landmark view of anatomy or pathology, while the patient was under anesthesia as happened to be the case that day. So Dr. Lapides had the first student in turn to look in the scope and asked: ‘Do you see the verumontanum?’ The student, after a few awkward moments said ‘Yes’ and Lapides checked the position and asked the next student, who again agreed. When it was my turn, I looked and looked and finally said ‘No.’ It turned out that the Professor was holding the scope in the middle of the full bladder, nowhere near the veru. He seemed to like me after that day and later in the rotation asked my career plans. I told him it was cardiology. He said: ‘Think about urology, and if it interests you, come back and talk to me.'”

    Montague did give some thought to urology and that changed his career arc and life. It was a clever and kind approach on the part of Lapides, kinder than the anecdotal “Black Jack” stories. [Below, Montague in his office at Cleveland Clinic, autumn 2019.]




    Five.

    Kindness & Kurt Vonnegut Jr. (November 22, 1922 – April 11, 2007). The Vonnegut books I read in college, medical school, and during residency offered great escape from study with humor, satire, and surreptitious insight into the thing we call, the human condition. More than appreciated at the time, Vonnegut expanded my sensitivities to the comorbidities of life, environmental deterioration, and the quality of kindness. Cat’s Cradle (1963), iconic book, offered very short chapters that fit my short extracurricular attention span. [Above: “Two Young Women Seated playing cat’s cradle.” Suzuki Harunobu, ca. 1765. Wikipedia.] Slaughterhouse-Five (1969, film 1972) didn’t mean so much to me then, but years later hearing a beautifully performed audiobook, I felt its powerful impact, reflecting Vonnegut’s lived experiences as a prisoner of war in the Allied firebombing of Dresden. Even though I served in a peacetime Army for four years after my residency training, I had gained enough maturity, experience, and knowledge to appreciate that mind-bending book. 

    Vonnegut told stories of contrived odd characters and places. While exaggerated and even preposterous, he resonated with the best and worst of human attributes. God Bless You Mr. Rosewater (1965) only came recently to me, as I was tracking a quote that reflects Vonnegut’s dark humor and the hope that underlies his satire. The quote came from an anticipated baptismal greeting:

    “Hello babies.

    Welcome to Earth.

    It’s hot in the summer & cold in the winter.

    It’s round & wet & crowded.

    On the outside, babies, you’ve got 100 years here.

    There’s only one rule that I know of, babies –

    God damn it, you’ve got to be kind.”

    T.S. Eliot once called April “the cruelest month” so it seems fitting to conclude now with thoughts of kindness, a trait that seems to come naturally to some people, but most of us have to work at it, balancing it against our selfish particularities. Kindness is a very human trait, the very basis of civilization, although many other creatures evidence kindness in numerous ways. Kindness is, no doubt, tied into mirror neurons, oxytocin, and other incredible biologic inventions that we are dimly aware of at best. Motherhood is the ultimate expression of kindness, perhaps that was on Hassam’s mind to some extent in April, 1920.

     

    Postscript.

    With few centurions living today, only historians can tell us much about what daily life was like during the big influenza epidemic of 1918-1920 that ended around the time Michigan Urology’s first century began. And, of course, one hundred years from today, will many people fully understand the anxieties, terrors, and tragedies of the present moment in time.

    Kindness is always at risk in the busy workplaces of healthcare, and this will be especially tested in this current pandemic threat (Coronavirus 19), that has taken civilization by surprise. We are too often surprised by infectious diseases, whether cyclic or novel and while our immune systems may be surprised, our brains have no excuse. Here is an amateur historian’s list of the last big pandemics:

    HIV/AIDS rising from 1976 to 1981 and peaking 2005-2012, killing 36 million

    Influenza H3N2 1968 killing 1 million

    Influenza H2N2 1956-58 killing 2 million

    Influenza H1N1 1918-1920 killing 20-50 million

    Sixth cholera pandemic 1910-1911, killing somewhat under 1 million, estimated.

    Influenza H3N8 1889 – 1890 killing 1 million

    Third cholera pandemic 1852-1860 killing 1 million

    Black Death (bubonic) 1346-1353 killing upwards of 200 million

    The Plague of Justinian (bubonic) 541-543 killing up to 25 million

    [Above: Red Cross volunteers assembling gauze face masks at Camp Devens, MA, 1918.] 

    Thanks for reading Matula Thoughts this April, 2020. It will be a rough month.

    David A. Bloom
    Department of Urology
    University of Michigan

    March thoughts, idle and otherwise

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    WN/MT 6 March 2020

    March thoughts, idle & otherwise
    2102 words

     

    One.

    Be cautious in mid-March, the spirit of Julius Caesar warns. It’s not idle advice, for Caesar must have had a tin ear to the political dissent building up around him, or else the mantle of authority made him feel unassailable until he was terminally disabused of that conceit on the Ides of March 15 in 44 BCE. A coin issued by Brutus two years after Caesar’s assassination (shown above) celebrated the would-be king’s downfall. Before the Ides of March became notorious, that day in the Roman calendar was reserved for religious observances and settling of debts. It so happens that the big settling of debts in American society two millennia later has been displaced a full month in the calendar to April 15 for taxpayers like me and businesses not clever enough to find the loopholes. [Above: Eid Mar coin reverse, the tail side. Below: Wikipedia, The Tusculum likeness of Julius Caesar, photographer Gautier Poupeau.]

    No one wants to be overly superstitious, but it is wise to venture forth with a measure of caution not only on the Ides of March but every day, monitoring your physical and political environments, on the lookout for “hungry looking” Brutuses and watching for reckless scooters, distracted walkers or drivers, rising seas, hurricanes, fires, blizzards, tornados, or merely uncovered sneezes and coughs. (By the way, why is it socially accepted that we expect ourselves or others to cover coughs or sneezes only when “feeling sick” with a fever? Why doesn’t every adult carry a handkerchief or tissue to cover every cough or sneeze – especially in these coronavirus times ?!)

    Ancient Roman days were counted differently than they are now, with three named points each month: the Nones in the early month, the Ides in mid-month, and the Kalends on the first of the next month. Assassination perp Brutus issued the coin in the fall of 42 BC, and that Eid Mar denarius shows a “freedom cap” positioned between two daggers.

    The denarius was the standard coin in the Roman Empire from 267 BC until replaced by the antoninianus in the mid-3rd century AD, the coin of Galen’s day. The silver in the coin was initially worth about a day’s wages for skilled laborers at that time in Rome, today that equivalent amount of silver is less than $4. Emperor Nero, about 100 years after Caesar’s assassination, began to debase the coin, substituting cheap metal for the silver, until hardly any silver was left by the end of its use. The Eid Mar value, however, has greatly appreciated – a single coin recently fetching 325,000 Swiss francs ($332,583) at auction on Oct. 6, 2016.

    [Above: Eid Mar coin obverse – the head side with Brutus. Below: Silver content debasement by year of Roman Empire denarius and its successors, 11 BC to 250 AD. Wikipedia: Data from Walker, D.R. (1976-78), The Metrology of the Roman Silver Coinage. Parts I to III. Nicolas Perrault III.]

     

    Two.

    Coffee Houses. My youngest daughter and her husband, both academics, do much of their work in coffee houses, as do many of their generation. Before computers and the internet, coffee houses were places to meet and converse. Now, it’s more common to see people with ear buds in place and eyes focused on their work on laptops and (annoyingly) on phones.

    The coffee house of Edward Lloyd on Tower Street in London around 1686 was the room where it happened that marine insurance blossomed and grew into an essential component of modern business and life. Insurance was a necessary ingredient in the emergence of the limited liability company, that is, the modern corporation underpinning modern capitalism. Coffee houses have been important social hubs for over 300 years in Western Society and the tea customs in Asia have been around much longer. The Cosy Corner Tea Shop of Mrs. Hugh Cabot opened in Ann Arbor 1923 and became a small part of the Michigan Urology story, with its own backstory of how social changes and the Great War changed expectations for one faculty wife. Coffee and tea houses today serve as primary places to plug into earpieces and computers so as to disconnect from people and immediate scenes around you and leap into distant people, scenes, and your own imagination. Oddly, socialization and social media are not very compatible.

    The Coffee House, in the winter of 1905/1906, a painting by Alson Skinner Clark (1876-1949), shows the State Street Bridge amidst smoke, fog, and early “skyscrapers” over an icy river. You can barely identify the actual coffee house. [Above: Institute of Art, Chicago.] The title suggests Clark either painted the scene in real time (en plein air) or recalled it from his time in the neighborhood, although he was also an accomplished photographer and may have used that medium to help fashion the painting. The view is not vastly different a century later, the high rises are higher and more numerous, the horsepower of street transportation has increased (without much increase in the transit time per mile), and the price of a cup of coffee has gone up. That same neighborhood these days contains at least several Starbucks and other coffee houses. [Below: State Street Bridge in early spring 2019 during AUA national meeting.]

     

    Three.

    Coffee beans. I can’t spend too long in coffee houses without recalling the great Danish story teller Karen Blixen, known more widely by her pen name, Isak Dinesen. Out of Africa in 1937, described her years in British East Africa (modern-day Kenya) between December 1913 and August 1931. She initially tried to raise cattle, but switched to growing coffee beans although that, too, proved difficult. The soil and high elevation were not perfectly conductive, East African conflicts in First World War interfered with supplies and equipment, and ultimately the Great Depression made the business untenable. Having run through her family’s money, Blixen returned to her family home in Denmark to write. Her work there proved far more successful and enduring than the Karen Coffee Company and she became a world celebrity, dying in 1962 at age 77. Orson Wells planned a film anthology of her work, but never completed it, producing only The Immortal Story (1968). Babette’s Feast (1987) became an extraordinary black and white film of a somber isolated Scandinavian village and Out of Africa (1985) was gorgeously filmed in color featuring Meryl Streep and Robert Redford. Last autumn, while at the terrific CopMich meeting organized by Dana Ohl and Jens Sønksen, I spent an afternoon at the Blixen family home in Rungstedlund. [Above: Photo by Sophus Juncker-Jensen (1859-1940) taken in 1913 shortly before Blixen’s departure for Africa. Below: Karen Blixen’s home, Rungstedlund, 2019.]

    The Isak Dinesen quote that comes to mind after an hour or so in a coffee house is from Seven Gothic Tales:

    “What is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.”

    Unpleasantly, the name Karen, like many other terms on social media, has become a derogatory meme. [Below: Wikipedia: Baroness Karen von Blixen-Finecke at Kastrup Airport CPH, Copenhagen 1957-11-02.]

     

    Four.

    A book on urine. In 1917, when Karen Blixen was cultivating coffee by day and telling stories to her friends at night and Michigan Urology founder Hugh Cabot was serving on the Western Front for the British Expeditionary Forces during WWI, Arthur Robertson Cushny, former University of Michigan professor from 1893 to 1905, was working at University College London when he published Secretion of the Urine, a book explaining the machinery and infinite artfulness of urine production. [Above: Cushny, Wellcome Museum. Below: title page.]

    Cushny took uroscopy to a new level of detail. Uroscopy began in ancient times with basic sensory evaluation of urine (color, odor, taste, etc.). Medieval uromancy offered speculative linkage of urine findings to diagnosis, and microscopic evaluation later opened new levels of visual detail. Chemical and microbial analysis, using 19th century tools and technology, provided meaningful therapeutic opportunities, but Cushny’s book of 1917, Secretion of the Urine, explained how urine was formed in health and disease, by filtration at the glomerulus and reabsorption/secretion along the renal tubules.

    Arthur Cushny (1866-1926) had come to the Medical School in Ann Arbor to replace John Jacob Abel, a UM graduate from 1883 who had returned to Ann Arbor in 1891 to teach, pursue research, and create the world’s first department of pharmacology. Abel transformed the formal and ancient lectures on materia medica and toxicology into pharmacology instruction with demonstrations applicable to clinical practice of his time. Johns Hopkins lured him away in 1893, but that opened the door for Cushny to replace him as chair. Dean Victor Vaughan found Cushny in Berne, investigating the problem of death from chloroform anesthesia and developing methods of titrating the delivery. Cushny was an effective teacher and a productive researcher in Ann Arbor, but returned to Europe for an attractive job as chair of pharmacology at University College London in 1905 and in 1918 returned to his native Scotland as chair in Edinburgh, where he died in 1926. Secretion of Urine was a major contribution to physiology and urology. [Cushny AR. The Secretion of the Urine. London, Longmans, Green, 1917.]

     

    Five.

    You are what you eat, like most aphorisms, contains truth and hyperbole. It extends easily to other bodily inputs such as you are what you drink. [Above: The Cook, Guiseppe Arcimboldo 1570. National Museum, Sweden.] Last month’s suggestion, that you are what you read, regarding on The Crisis periodical, fortifies a parallel claim for mental nutrition, which came to mind again in another magazine that compels interest, The Economist. A recent piece in the recurring essay entitled “Johnson” (after Samuel Johnson, of dictionary fame), combined the recent custom of selecting “words of the year” and the phenomenon of adverse climate change. “Johnson” offered a number of candidates for word of the year, noting that according to the Dutch dictionary Van Dale, Dutch-speaking Belgiums voted for winkelhieren, a term for “buying locally,” as the 2019 word of the year. [Economist Jan 4, 2020, p. 62.]

    Ann Arbor offers excellent examples for buying locally including Zingerman’s and Kerrytown markets for food and stuff, Literati for books, or Camera Mall for photographic things. Amazon is convenient, luring, and addictive but it robs from local communities (livelihoods and taxes). Plus, given the packaging and reported 30% return rate, that particular limited liability corporation accelerates planetary degradation. Perhaps a community becomes what it buys. If people buy mainly from Amazon, they will be an Amazon community as local businesses recede like the glaciers – not such an attractive possibility.

     

    Postscript x 2: peas and war.

    Gastronomic identity. In 1826 Anthelme Brillat-Savarin wrote, in Physiologie du Gout, ou Méditations de Gastronomie Transcendante: “Dis-moi ce que tu manges, je te dirai que tu es.” [Tell me what you eat and I will tell you what you are]. In 1940, Victor Lindlahr, nutritionist and enthusiast of the so-called catabolic diet, wrote a book You are what you eat: how to win and keep health with diet. In strict chemical and physiologic terms, it’s hard to deny that fact, although it’s nice to believe the human sum is actually greater than the sum of its nutritional parts, as the Italian painter Guiseppe Arcimboldo (1527-1593) hinted in his arresting works, such as Vertumnus. [Above: Emperor Rudolph II as Vertumnus, Roman god of seasons. c. 1590, Guiseppe Arcimboldo. Skokloster Castle, Sweden.]

    The Battle of Columbus. Just around this time of year, in 1916 (March 9), Francisco “Pancho” Villa’s División del Norte raided the small border town of Columbus, NM and retreated back to Mexico. United States President Woodrow Wilson, while holding the U.S. back from the Great War in Europe (that Hugh Cabot entered as a volunteer with the British Expeditionary Forces) eagerly sent 4,800 U.S. troops led by General John Pershing over the U.S./Mexican border to capture Villa. [Above: Unmindful of the Ides, U.S. troops crossed into Mexico in March 1916 in pursuit of Pancho Villa. Photo courtesy U.S. Army Military History Institute.] The 9-month punitive incursion south of the border failed to capture Villa, but it did recruit University of Michigan Ph.D. Paul de Kruif, who joined as a private. The campaign ended in January 1917, without achieving its objective. Pershing claimed the effort a success, even though it seemed that the U.S. soldiers were the main parties punished. de Kruif went on to join the WWI effort after the U.S. officially entered the conflict, serving in the Sanitary Corps as a lieutenant and then captain before returning to Michigan for a short time. His next job was at the Rockefeller Institute until he was fired, rendering him the freedom to become a medical journalist and collaborator in 1926 with Sinclair Lewis in Arrowsmith.

     

    Thanks for looking at this month’s communication from the University of Michigan Department of Urology. What’s New is the email version and matulathoughts.org is the web-based version.

    David A. Bloom