Spring and all

DAB What’s New Apr 6, 2018

Spring and all

3476 words

 

One.

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

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

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

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

 

Two.

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

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

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

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

 

Three.         

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

[Above & below: morels]

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

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

 

Four.

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

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

 

Five.

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

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

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

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

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

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

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

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

 

Six.

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

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

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

 

Nine.

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

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

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

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

 

Ten.

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

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

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

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

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

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

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

Why on the evidence of pictures is everything important?

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

 

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

Thanks for reading Matula Thoughts this April, 2018.

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

 

Marginalia

DAB What’s New Mar 2, 2018

 

Marginalia of sorts
3732 words

 

One.

Marginalia. As a young reader I recall making casual sideline notations in margins of my books and, in time, detailed marginalia, underlining, and highlighting expanded into my college and medical school textbooks. Later, during residency I heavily personalized my pages of Campbell’s Urology trying to digest them intellectually.

The habit persists and marginal notes help make sense of what I read and leave reference points to which I can easily return. Other reading has replaced textbooks my marginalia drifted to and consolidated on end pages, creating personalized indices of page references and related comments (below “end-page marginalia” in Harari’s Sapiens).

Marginalia-making has been a human habit ever since books existed with numerous famous examples as early as amusing marginal drawings by monastic scribes alongside their serious transcriptions. A notable marginal comment unsettled the world of mathematics for nearly four centuries after French lawyer Pierre Fermat wrote in the margin of a book he was reading in 1637 that he had solved a puzzling mathematical conjecture, but claimed his solution was too large to fit the margin.

The book was a 1621 edition of Arithmetica by 3rd century mathematician Diophantus and its actual margin looks generous by my standards, although I am no mathematician. [Above: Wikipedia, public domain.] It may never be known if Fermat’s solution was correct or if he was joking, although he didn’t seem much of a jokester and his other mathematical work was accurate. Furthermore, his unsubstantiated comment was taken so seriously that it was included in later editions of Arithmetica (below: Wikipedia).

Many others tried and failed to solve Fermat’s Conjecture over the next three centuries until 1994 when British mathematician, Andrew Wiles, came up with the answer.

Scribbling in the margins of library books or books of your friends is bad form, but marginalia in personal materials conveniently identify meaningful passages or record pertinent or tangential thoughts. Some mental process pauses readers from reading long enough to acknowledge the adjacent text in some way. Marginalia are evidence of our effort to find meaning in the things we encounter.

Electronic books allow similar personalizations, although it’s not quite the same, in part because electronic screens lack the comforting tactile sense of paper. Electronic formats, however, offer new opportunities and challenges for marginalia: private marginalia can become public, aggregated, and analyzed. Audio books allow listening as we close our eyes or move physically through life, but as much as I like audio books when driving, the opportunity to make marginal notes is problematic and any spontaneous thoughts I have when hearing certain passages are usually gone from memory by the time I’ve reached my destination.

 

Two.

The compulsion to annotate or otherwise leave personal evidence of one’s presence or thought pre-existed books and is widely exercised on other cultural artifacts and the environment-at-large. Cave paintings, rock carvings, initials on tree trunks, furniture inscriptions, children’s heights on door frames, and urban graffiti are footnotes of ourselves and plant notice of us for the future. The cliché George Washington Slept Here was a 1942 play and film about a couple who moved into a run-down farmhouse (because of their dog) and they discover the first president actually stayed there during the Revolution.

The top of this posting shows a section of the Berlin Wall that faced the free part of the city, while below you see the unmarked reverse side that faced the Soviet side. These sections are on display in Washington, DC at the Newseum and were salvaged after the wall came down in 1989. The contrast is stark.

Urban graffiti, as annoying and vulgar as it can be, are an expression of personal freedom and the 45 words of the First Amendment that represents a core belief of our representational democracy.

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.”

A video display at the Newseum displays interviews on a random street showing that people are far more likely to be able to identify all the members of Homer Simpson’s cartoon family than to know the five freedoms of the First Amendment (religion, speech, press, assembly, and petition of the government). The video references national surveys that support this unfortunate observation showing 20% of Americans can recall all Simpsons, whereas only 3% know all five freedoms.

The marginalia habit fills the strong human compulsion to seek relevance and meaning, a need played out in many ways including early forms of social media content; “Kilroy was here,” “George loves Tina,” and their equivalents have been expressed by our species since the earliest human days. Graffiti as urban social marginalia, occasionally becomes valued public art such as the works of anonymous British artist known as Banksy. [Below: a Banksy image from Wikipedia.]

Historical plaques and other public commemorations are structural marginalia, we mentioned those of the old Ann Arbor Bus Station, last month, on the Residence Inn in downtown Ann Arbor. Historical markers are marginalia of place. You can find plaques at the Michigan Union on the top front landing step and on the building wall commemorating the first occasion that John F. Kennedy publically articulated the Peace Corps idea. It was during a campaign speech October 14, 1960 at around 2 AM, a remarkable time for a presidential campaign speech that highlighted the vigor of the young presidential candidate. Arriving from New York in those early hours he went directly to the steps of the Union where a crowd of around 5000 students was waiting on State Street. Kennedy began his remarks by describing himself as “a graduate of the Michigan of the East, Harvard University.” He spoke about the importance of public service, asking for young doctors and engineers, as an example, to spend a period of time in Ghana or other places. You can find the speech on YouTube and he concluded:

“I come here tonight to go to bed, but I also come here tonight to ask you to join in the effort! This university – this is the longest short speech I’ve ever made and therefore I’ll finish it. Let me just say in conclusion that 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 asking for your support for this country in the next decade.”

It was an inspiring speech. As an aside, the official portrait of Kennedy (above: painted by Aaron Shikler, whom Jackie Kennedy selected after the assassination) is on display at the Smithsonian National Portrait Gallery, along with all presidents up through Barack Obama (recently unveiled). The Kennedy portrait is the only image of a president looking down and away from the viewer, that having been Jackie’s choice.

Kennedy’s idea continues to tap into a compulsion for relevance and meaning that many students and others feel so acutely. The Peace Corps, finalized in law in the first months of his presidency, continues to resonate with college students across America. Since 1961 Michigan has been among the top four contributors to the Peace Corps with 2720 students volunteering since 1961 (after Berkeley, Madison, and Washington. [Mandira Banerjee. Feb 21, 2018. The University Record.]

 

Three.

Eleven years ago today, 2 March 2007, was the second day of my time as chair. Going to my computer I found digital images from that time in our department, including this early picture (above) of the board in my office. This has served as my functional marginalia for the Department of Urology for the past 11 years. Faculty are in the boxes on the sides and activities, units, and projects in the middle. The board changed over the years as we grew and became more complex. The picture below shows one of our visits to the billing center in the KMS Building south of I 94. Jack Cichon (now retired) was our stalwart Chief Department Administrator (CDA) and Malissa Eversole was then his understudy, having since then come into her own as our current CDA.

Below you see Ed McGuire in the center with 2 of his former fellows (now faculty) on the left (Anne Pelletier-Cameron and Quentin Clemens) plus Stu Wolf (faculty) and Walter Parker (resident) on the right.

Since 2007 the changes in healthcare education, research, and clinical delivery have been head spinning. Today the UM Medical School and health care system is rebranded as Michigan Medicine.

The time has flown by, in my mind, and if this present interval of stewardship of the Department of Urology is deemed successful in any measure, the success is due overwhelmingly to our faculty, our residents, our nurses, our physician assistants, our researchers, and our staff. Sister departments in the Medical School and this great University also account for our success; we flower in fertile soil.

This success should continue to grow with our next departmental leader whom I hope will help our clinical divisions and team do their jobs optimally, as I have tried to do. We want to avoid a repetition of the darker events of the 1990’s (as duly recorded in the Wall Street Journal and the Detroit Free Press), when Ed McGuire’s successful term and Bart Grossman’s interim stewardship were interrupted by a few difficult years until Jim Montie’s leadership brought us into departmental status and initiated the Dow Health Services Research Division. [Below: Khaled Hafez, Hugh Solomon, Jim Montie.]

 

Four.

March brings Spring steelhead to mind. It’s been many years since I’ve been on the Pere Marquette River thigh deep in waders feeling the rush of icy water working its way toward Lake Michigan. Migrating steelhead salmon, pressing retrograde to reconcile with their past, have few things on their minds at that stage and feeding is not high in their priorities. Lures need not be very sophisticated or authentic, as the fish are on their migration to spawn so they are as likely to bite out of anger or random habit than culinary urge. [Above: Brent Hollenbeck and steelhead. Photo credit: Jeff Montgomery.]

Steelhead rainbow trout (Oncorhynchus mykiss) hatch in inland streams and then swim downstream to forage in the Great Lakes (or the ocean, on the west coast) for 2-3 years. Winter-run steelhead are sexually mature and generally have a shorter run to their spawning grounds, whereas the summer-run steelhead are sexually immature when they leave the lakes or ocean and travel deeper inland. Actual spawning for either type happens in late winter or spring. These Pacific rainbow trout were introduced as immigrants from California to the Au Sable river around 1876 and after many generations are well established residents although state-managed hatchery programs supplement the existing wild fish.

Steelhead provide a loose metaphor for medical professionalism. We train our successors in the streams of academic medical centers and on maturity they go off to do their thing in the wide world. Toward the end of their careers many of them want to reconcile with their origins and travel back upstream to check out their starting points. Forgive me for stretching this analogy, but I do want to put in a plug for our Nesbit alumni, former students, and friends of the department to come back for one of our academic events, particularly in the next two years as we gear up to celebrate the Centennial of Urology at Michigan in 2019-2020.

 

Five.

Fish and urologists. Fish have twofold purposes. Primarily they pass along their DNA to their successors and secondarily they serve the larger planetary ecosystem. The optimal life span of a steelhead allows 4-6 years for one or more foraging careers in the wide world, although some Pacific steelhead live as long as 11 years and grow to 55 pounds and 45 inches, according to the National Oceanic and Atmospheric Administration (NOAA) Fisheries website.

Medical professionals have a fundamental purpose of caring for their fellow creatures, motivated by genetically crafted mirror-imaging that produced the essential human phenotypes of kindness and empathy. Secondarily, healthcare people serve their ecosystem by educating their successors and expanding the armamentarium of knowledge and technology. The career of a urologist is 40 years, give or take a decade, foraging in the real world of clinical medicine. While steelhead must adapt to gradual warming of the oceans, urologists need to adapt to rapid changes in knowledge, technology, and regulatory matters. Technology and market forces are driving changes in urologic practice at least as much as scientific evidence, leaving practitioners and patients sometimes uncertain of what treatment fits best.

 

Six.

Urologists are skilled in techniques and technology to solve urological problems but, no less than any other physicians, urologists also offer their personalities, opinions, and reassurances to patients throughout interactions that are bundled under the unfortunate label “encounters” in today’s workplaces and medical records. The language and demeanor experienced by patients often are just as meaningful to them as any treatment or technology. Indeed, the non-technical aspects of the encounter may impact the patient more than any specific medical service. This is a prime difference between the professional and a commodity natures of health care. People, as patients, treasure the right human touch.

The essential deliverable of our department is kind and excellent patient care, thoroughly integrated with education and innovation at all levels. This is not just our priority, but the priority of Michigan Medicine. Below is another picture I found from 2007 showing a faculty member and two residents who exemplified that essential deliverable back then and do so today in their new locations: Gary Faerber, now at the University of Utah; Emilie Johnson, faculty at Lurie Children’s Hospital and Northwestern Medical School; and Kathy Kiernan on the right, faculty at the University of Washington and its children’s hospital.

The human touch is also conveyed by words. A recent Viewpoint in JAMA by Arthur Barsky of the Department of Psychiatry at Brigham and Women’s Hospital is worth reading. [Barsky. JAMA. 318:2425, 2017]. The title sums it up: The iatrogenic potential of the physician’s words. Barsky invokes viscerosomatic amplification to explain how a physician can affect through words and attitude. (As is usual on these pages, we use physician as a synonym for healthcare provider.) Techniques and technology are unquestionably at the core of urologic practice, but the art of clinical practice is far more than its tools and treatments. Kindness, words, and professional touch are no less essential.

 

Seven.

Expectation. Human brains add further dimensions to medical treatments, with the matter of expectation. Every treatment carries the possibilities of real benefit or harm, but another two-edged sword exists in our capacity for imagination, something we cannot easily turn off. We may readily imagine benefit even when no physical or physiologic benefit can be explained (the placebo effect) or we may imagine elements of harm (nocebo).

Placebo and nocebo effects confound medical treatments when a therapy (legitimate or bogus, scientifically-validated or apocryphal) has a more positive or more negative effect than it rationally should have. This reflects changes in psychobiology rather than changes in physiology, pharmacokinetics, or other factors that are directly measurable or attributable to the treatment.

Nocebo, the evil twin to the placebo, is a term coined in 1961 by WP Kennedy. [Kennedy WP. Med World. 1961; 95:203, 2013.] The evil twin metaphor came from Michael Glick in an editorial in the Journal of the American Dental Association. [Glick M. Placebo and its evil twin, nocebo. JADA.2016; 147:227.] The nocebo effect occurs when negative expectation of therapy exacerbates the negative effect that the treatment rationally would cause. For some patients a given therapy, let’s say a radical prostatectomy, in addition to successfully removing a malignancy (from which direct harm might have been years away) with minimal detriment to related anatomic structures, might produce a sense of relief that carries with it additional placebo effect. For other patients a nocebo effect negatively magnifies the overall therapeutic experience and collateral damage of any attendant detriments. Every patient responds individually and idiosyncratically to an expectation and to a treatment. These phenomena, placebo and nocebo, should be anticipated for almost everything we offer in healthcare, and to the extent that we understand these possibilities and prepare patients and their families for them, we will improve the patient experience. This is one of the myriad ways that complex health care cannot be easily managed as a commodity or by artificial intelligence.

 

Eight.

As scientific medicine emerged in the 19th century it consolidated into subspecialty medicine in the 20th century and anatomic, physiologic, and microbial determinants became the focal points of healthcare. Cognitive and social factors were “marginalia” of most patient encounters. Now, in the 21st century it is clear that cognitive and social factors are equally important parts of everyone’s healthcare needs. Our profession and its business are no longer accurately described as the matter of “medical care”, but rather the matter of health care.

A prescription for a treatment or an operative procedure may be based upon symptoms and observations as entered into checklists and databases. Emotional responses and social determinants are not so easily factored in electronic medical records, particularly within the constraints of time-constrained encounters. Watson and other artificial intelligence systems are working their way into examining rooms, bedsides, and operating theaters, but these are not as effective in sensing the co-morbidities, social determinants, and other “marginalia” of the human condition, as is an attentive and kind human being. Artificial intelligence engenders great enthusiasm, but humanity should never surrender its ultimate agency to algorithms created by a self-empowered cadre of programmers.

 

Nine.

Considering gaps last month, including astronomical gaps, calendar gaps, and geological gaps, we saved an important one to mention now. A gender gap has long been present in the field of urology, although Michigan more than most other training programs began to change that imbalance, starting with Carol Bennett, who trained under Jack Lapides and was Michigan urology’s first woman graduate. Carol is now on the faculty at UCLA. In her era of training women in urology were rare. Today the situation is quite different and at Michigan we have had residency classes where women outnumber men three to one. Other years we have returned to 100% men and some year soon we could as easily have all women. In our selection process, we don’t aim for an optical effect, but rather try to pick the best talents and fits for our department from the yearly applicant cohort. Ultimately, individuals from the candidate pool make their selections when they rank the programs. [Below: Peter Knapp, Nesbit 1985 and Carol Bennett, Nesbit 1983.]

Women graduates from the University of Michigan Medical School and women trainees from our urology training program (all are considered Nesbit Alumni) are making significant impact in the world of urology, academically and in the private sector. Below you see a dinner at the recent annual meeting of the Society of Women in Urology. From the left: Cara Cimmino UMMS and faculty at Emory, Priyanka Gupta UM urology faculty, Allison (Lake) Christie Nesbit graduate and urologist in Tennessee, Miriam Hadj-Moussa Nesbit graduate and UM urology faculty, Lindsey Herrel Nesbit graduate and UM urology faculty, Akanksha Mehta faculty at Emory, Amy Luckenbaugh UM resident, and Annie Darves-Bornoz resident at Vanderbilt.)

 

Ten.

John Hall, Nesbit Alumnus 1970, wrote recently and gave me permission to give his note wider distribution here in Matula Thoughts. I came to know John after I came to Ann Arbor, largely through his high-quality practice, a sliver of which I appreciated through his pediatric referrals, as well as his local care of people I knew in the Traverse City area where he worked. Letters like his are one of the great pleasures of mine with What’s New our monthly email and it’s sibling Matula Thoughts, the web version. As we get closer to our Centennial and to reformulating our departmental history, his recollections, and perhaps yours as well, will be important to us.
From John:

“Hi Dave, I was just reading your letter of December 21, 2017. It made me think of the 5-6 doctors who staffed Urology during my training. Your staff will be limited to how many names you can put in the letterhead margin. It’s like how many doctors can fit on the head of a pin.

I finished my training in 1970, Urology 50. By 2020, Urology 100, if I’m still kicking I will be one of the few to span the history of the department. I started my contact with Urology as a student and served as a “nurse” in the Urology dialysis center. I took the vitals as the residents stirred new electrolytes into the Kolff Twin Coil Baths. As a result, I knew many of the residents from the fifties and sixties. Also, since I was appointed to residency by Dr. Nesbit, I met many of his trainees who now directed new urology departments, when they returned to AA [as visiting professors or guests], I also once met Dr. Huggins.

Dr. Nesbit retired in 1967, six months into my residency. So my group became Lapides 1. I’m not going to measure up to your knowledge of urologic history, but I am willing to provide my perspective of Michigan Urology to the Centennial Committee. Please let me know if I could provide some value to the process. Please keep writing Matula Thoughts, the highlight of my month! … John.”

Thank you, John and yes, please continue your perspectives! Much is contained in John’s brief note: the idea of 100 years of urology in AA, the imprinting of students, the Kolff “artificial kidney”,  Nesbit alum and Nobel Prize winner Charles Huggins, and the long list of chairmen Nesbit trained. Overstated only is the disproportion of historical knowledge between me and John – he knows vastly more about that midpoint in Michigan’s urologic story and I hope we can get as much as possible in print for you and others to understand our perspectives.

Since that note, John sent me a copy of his book “I’d Rather Be Sailing” and I expect to go through it and decorate it thoroughly with my own marginalia. As we reconstruct the 100-year story of Michigan Urology it will be the personal marginalia of alumni such as John Hall that provide the context, color, and personalities to illuminate the names and dates of our narrative.

 

With a few weeks until Spring, 2018, best wishes from David Bloom and Michigan Urology.

Transitions.

DAB What’s New Dec 1, 2017

3818 words

 

One.

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

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

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

“`

 

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

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

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

 

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

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

 

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

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

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

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

 

Five.

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

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

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

 

Six.
Michigan men.

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

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

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

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

 

 

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

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

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

 

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

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

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

 

Nine.

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

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

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

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

 

Ten.

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

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

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

 

[Neighborhood leaves, in transition, 2017]

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

November matters

DAB What’s New Nov 3, 2017

3742 words

One.
The matula, an historic symbol of the medical arts and title of this electronic periodical, was the transparent beaker used to examine urine in the pre-scientific days of health care, as people sought explanations for and expectations from their illnesses. Fear and uncertainty exacerbate human illnesses and our earliest prehistoric ancestors found comfort from their fellows in clans and caves to care for and sometimes heal them. The matula is a useful metaphor for the acts of looking, listening, and examining evidence to discover what really matters in clinical situations.

In ancient days what really mattered to people with illness or injury were the issues of treatment and prognosis: what can be done to help, what comes next, will I live, or will I die? The specific matter of diagnosis was most likely subsumed by the idea of what caused the problem. Gods, fates, cosmic forces, evil-doers, bad luck, or obvious injury were likely culprits before germ theory, organ-based dysfunctions, or other explanations based on a verifiable conceptual basis of health and illness. A sense of prognosis, however, was of practical value.

Uroscopists inspected urine for color, consistency, clarity, sediments, smell, and sometimes taste of urine, to find clues for treatment and prognosis. This was not illogical. Pink urine from infection or trauma might be followed by recovery. Gross blood and particulate sediments would suggest recurrent bladder stones. Scanty concentrated urine from dehydration might signal severe gastroenteritis and a grim prognosis. Uroscopy grew into a complex pseudoscience with fanciful claims of prognostic significance based on intricate characteristics of urine samples. Newer tools, such as the stethoscope and microscope superseded matulas and the future will bring better tools.

Thoughts about the future occasionally slide into dystopian visions and invite the question: what really matters to each of us? Putting aside occupational questions of healthcare professionals (making a diagnosis, ascertaining a treatment), political ideology (conservative or liberal, R or D, libertarian or socialist), or pragmatic issues (where do I live, what car do I drive, what’s for lunch?), we each have our own beliefs, although ultimately most people share similar fundamental desires for safety, comfort, and peace of mind. Family and friends matter.

We cherish personal liberty, physically and intellectually. Beauty, curiosity, and clarity matter. Social matters are important to most people; kindness, truth, integrity, respect, belonging, and sustainability are essential in a civilized world. The last item may seem a bit out of place, but as we sustain health, welfare, independence, and safety, for ourselves, our families, our communities, and our descendants, by simple logic we need to sustain our environment.

 

Two.


With Michigan’s gorgeous autumn colors fading in the rear-view mirror, November’s matula brings Thanksgiving into sight and notably the iconic holiday images of Norman Rockwell. His Four Freedoms paintings, based on Franklin Roosevelt’s State of the Union Address in 1941, illustrated the freedoms that FDR thought mattered greatly: freedom of speech, freedom of worship, freedom from want, and freedom from fear. These freedoms extended the sense of the liberty entrenched in the second paragraph of the Declaration of Independence.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness, – that to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, …”

Roosevelt’s four freedoms are more specific than the liberty mentioned in The Declaration at the dawn of the Revolutionary War, although political liberty was not far from Roosevelt’s mind when he gave the speech 11 months before the U.S. entry into World War II. The speech also slyly broke with America’s non-interventionism, by advocating support for our allies already in armed conflict. The words of Roosevelt and paintings of Rockwell mattered greatly to Americans in the 1940’s and they seem to matter now in this new century. Rockwell’s Four Freedoms paintings appeared in the Saturday Evening Post in 1943 and were used in war bond posters and postage stamps.

Rockwell also painted enduring images of healthcare professionals, some modelled on his neighbor Dr. Donald E. Campbell. After this topic was discussed in previous pages of WN/MT (March 4 & May 6, 2016) the doctor’s great granddaughter, Moira Dwyer, kindly sent us information and photographs that the family kept. Dr. Campbell, born in 1906, graduated in 1939 from Middlesex Medical School and practiced in Stockbridge, Massachusetts providing nearly the full spectrum of medical care to his community. He retired at 83 and died in 2001 at 95. Like the English physician, John Sassall, detailed in John Berger’s book, A Fortunate Man, Campbell was an indelible part of his community, providing far more than clinical services for patients by going beyond the specificity of medical conditions of his patients to understand their co-morbidities, inner needs, and social constraints. [Matula Thoughts Oct, Nov, Dec. 2016 & Feb. 2017]

As a footnote to Dr. Campbell, Middlesex College of Medicine and Surgery was founded in 1914 in East Cambridge, Massachusetts and was affiliated with a hospital of the same name. The campus moved to Waltham in 1928 and by 1937, it also included schools of liberal arts, pharmacy, podiatry, and veterinary medicine in addition to its school of medicine. Accreditation by the AMA became problematic, ostensibly due to issues of funding, faculty, and facilities although many claimed the merit-based admission policy and unusually diverse student body of Middlesex grated on the far more homogeneous American medical establishment at mid-20th century. Medical schools then maintained ethnic and religious admission quotas and Middlesex was an unabashed outlier with its diverse student body. In 1946, the Middlesex trustees transferred the charter and campus, with the hope that the medical and veterinary schools would be continued, to a foundation that created Brandeis University two years later. Middlesex Medical School did not survive the transition to the new university.

 

Three.
It is a profound community asset to have a Campbell or Sassall and it is impossible to fully measure their impact as a citizen, leader, mentor, and role model. These essential anchors of society bring not just their professional skills, but also their values, leadership, and expectation of fairness to a community. They look out for the common man and particularly for the most vulnerable members of the community. It is no coincidence that a universal ploy of anarchists, revolutionaries, and authoritarian pretenders as seen widely across the planet, is assassination of these “honest brokers.” The moral example and leadership of doctors such as Campbell and Sassall is our ultimate expectation for the medical professionals we teach. These mentors and role models act as epigenetic factors for the larger “superorganism” of humanity. They are operational factors between human genetics and civilization.

Education and training of physicians changed since 1939 when Campbell graduated medical school. The 4-year curriculum deepened with the growing scientific basis of biology and disease while graduate medical education (GME) also expanded with enlarging technology and new specialties of health care. The period of residency practice and study is now the career-defining facet of a doctor’s learning. Nearly 80 years since Dr. Campbell’s graduation, medical students enter fields of GME in as many as 150 areas of focused medical practice with learning experiences that may exceed twice the years the trainees spent in medical school.

Healthcare education differs from that of lawyers, engineers, and most other career paths. Physicians, pharmacists, nurses, and dentists require an immediate educational context of patient-care. The University of Michigan recognized this fact in 1869 when it converted a faculty house into a hospital, thereby becoming the first university to own and operate a medical center. We recognized this anew when we began to create a wider health care network, in the past few years, capable of supporting our large educational mission, now educating 900 MDs and health care PhDs, 1100 residents and fellows in medicine, as well as dentists, nurses, and pharmacists. One could easily argue that universities should offer a wider coherent educational milieu. A grander educational vision to include all parts of the health care workforce (physician assistants, surgical scrub technicians, medical assistants, etc.) would have a great effect on state economy and on our workforce pipeline. It could be done with robust partnerships not only with the UM Flint and Dearborn campuses, but also with our adjacent and regional community colleges.

 

Four.
In its more rudimentary days, the UM academic health center was distinguished by its implementation of  fulltime clinical faculty, terminology indicating that physicians who practiced or taught exclusively within a teaching hospital had a fulltime salary independent of their patient care revenue at that site. In the early days of UMMS this model attracted national luminaries such as Charles de Nancrede in 1889 and Hugh Cabot in 1920. de Nancrede was an attending surgeon and clinical lecturer at Jefferson Medical College, among other Philadelphia medical institutions, and was a major name in American surgery as a clinician, teacher, and pioneer in antiseptic and aseptic technique. At Michigan he presided over the construction of the new West Hospital in 1892, established a world-class surgery department where he practiced exclusively, and wrote an influential textbook of surgery. [World J. Surg. 22:1175, 1998.] Cabot was an even more stellar addition, coming from Boston as an internationally known urologist, where he had become disillusioned by the monetary nature of medical practice.

The world of healthcare practice, education, and investigation is different in the 21st century. The few academic medical centers that will survive well in the future will be those with the best and brightest geographic fulltime faculty, the majority of whom will be busy clinicians. Their milieu may well depend upon robust clinical productivity that brings the most challenging clinical problems to them and their facilities, but this will also require a very substantial volume of more routine clinical work as the context for education of all learner groups and clinical trials, in addition to inspiring basic science investigation. This clinical milieu will require a robust array of endowed professorships to give faculty a modest disconnect from clinical practice to allow teaching and academic work.

 

Five.

Fellow professionals. Modern specialty-based health care has shifted emphasis from individual all-knowing utility-player doctors like Campbell and Sassall to large teams that deliver their parts of today’s healthcare. The knowledge base, growing list of specialties, and technology of medicine today is so great that the centrality of a single physician is a model that no longer works well for health care delivery. Furthermore, linguistic confusion arises as other terms are awkwardly deployed to indicate all healthcare providers (not just physicians) more inclusively. This matter became acute as we have been creating bylaws for our new University of Michigan Medical Group (UMMG). A good nomenclature solution arose from Gerald Hickson, a Vanderbilt pediatrician (above), speaking to the UMMG this summer about programs that build professionalism and create a culture of safety. His phrase, fellow professionals, nicely includes MDs, DOs, nurses, PAs, physical therapists, podiatrists, occupational therapists, optometrists, respiratory therapists, pharmacists, medical assistants, etc. [Hickson et al. A complementary approach. Acad. Med. 82:1040, 2007]

 

Six.
Medical professionals are under stress today from many sources, but the idea of a career in medicine still drives some of the best and brightest young people into our work, as judged by the medical school and urology residency applicants we see each year. I’ve just read applications, personal statements, and letters of recommendations from nearly 70 candidates for our 4 positions to start next July, and again I am blown away by the breadth and depth of these fourth-year medical students who will, all too soon, become our successors as urologists. They will have to resist the pressures to commoditize, corporatize, and industrialize their work as the 21st century rolls along. The electronic record is one of the pressures. A paper in Health Affairs last April surveyed primary care physicians and found they spent 3.17 hours on computers (desktop medicine) for every 3.08 hours spent with patients. [Tai-Seale et al. Electronic health record logs. Health Affairs. 36:655, 2017.]

It is impossible to predict the world that will envelop our successors. The conceptual basis they will learn and the skills they acquire are merely momentary assets. Ideas and techniques will change as long as human progress continues. The values, mores, social skills, curiosity, imagination, and ultimate kindness of our successors will be the principle assets to distinguish their careers, their effects on their communities, and their value to society in general. The influence of their ambient role models is as important as the book-learning and clinical skills imparted in graduate medical education. The epigenetic nature of values, mores, social skills, and role models show us, our colleagues, and our successors how and when to deploy the vast stores of information and skills we have accumulated. Just as importantly, some among them will be inspired to discover new knowledge and develop new skills.

 

Seven.

With Thanksgiving coming up, I’m appreciative for precarious and relative world peace, food security, respite from climactic disasters, and the happy, healthy, lives we may have. [Above: Jennie Augusta Brownscombe, The First Thanksgiving at Plymouth, 1914, Pilgrim Hall Museum, Plymouth, Massachusetts.] The great minds who have made this world so interesting are another blessing, people who looked at the world with clarity to make observations or find patterns that escaped everyone else at their moments.

The name, Conrad H. Waddington, probably doesn’t spring to mind, but is worth consideration. Born on a tea estate in Kerala, India, around this time of year in 1905 this British developmental biologist introduced the concept and word epigenetics. At age four he was sent off to England to live with family members while the parents remained at work in India for the next 23 years. In England, a local druggist and distant relation, Dr. Doeg, took the boy under his wing and inspired his interest in sciences. At Cambridge, “Wad” took a Natural Sciences Trips (a flexible curriculum across sciences) and earned a First in geology in 1926. With a scholarship he studied moral philosophy and metaphysics at university, assumed a lectureship in zoology, and became a Fellow of Christ’s College until 1942. During WWII he was involved in operational research for the Royal Air Force, and in 1947 became Professor of Animal Genetics at the University of Edinburgh where he worked for the rest of his life except for one year at Wesleyan University in Connecticut. Waddington’s landmark paper in 1942 begins with four lovely sentences.

“Of all the branches of biology it is genetics, the science of heredity, which has been most successful in finding a way of analyzing an animal into representative units so that its nature can be indicated by a formula, as we represent a chemical compound by its appropriate symbols. Genetics has been able to do this because it studies animals in their simplest form, namely as fertilized eggs, in which all the complexity of the fully developed animal is implicit but not yet present. But knowledge about the nature of the fertilized egg is not derived directly from an examination of eggs; it is deduced from a consideration of the numbers and kinds of adults into which they develop. Thus genetics has to observe the phenotypes, the adult characteristics of animals, in order to reach conclusions about the genotypes, the hereditary constitutions which are its basic subject-matter.” [Waddington. Endeavor. 1: 18-21, 1942]

Later on the first page he suggests the term epigenetics to encompass the “whole process of developmental processes” that carries genotypes into phenotypes. The influence of Dr. Doeg, whom Waddington called Grandpa, was no doubt significant. The specifics of Dr. Doeg eluded me as I read about Waddington. Too bad, because it would have been illuminating to understand the nature of the fruitful mentorship that shaped Waddington’s curiosity, lucidity, communicative skills, and sociability that left him a context to discover what he did.

 

Eight.

Black Bart, legendary stagecoach robber, committed his last robbery on this date in 1883. He specialized in Wells Fargo robbery, and it’s a bit ironic that the bank’s more recent history indicates it has internalized that larcenous bent to its own customers. Black Bart was actually Charles Earl Boles, variously known as Charley Bolton, a gentleman bandit in Northern California and Oregon. Born in Norfolk, England, he and his brothers joined the California Gold Rush in 1849. The brothers died and by 1854 Charles was married and living in Decatur, Illinois with a wife and four children. After serving in the Civil War he returned to California and gold prospecting in 1867, leaving his family behind. In 1871 Bolton wrote his wife and described an unpleasant encounter of some sort with Wells Fargo & Company agents and vowed revenge. He fulfilled the vow, adopting the name Black Bart, and robbed at least 28 coaches in California and Oregon, although never fired a weapon or harmed anybody. The last known robbery was in Calaveras County, between Copperopolis and Milton, when he was wounded in the hand while escaping. Detectives found personal items at the scene and through laundry marks traced a handkerchief to a San Francisco laundry on Bush Street. They quickly located Boles, living in nearby boarding house, and convicted him of the November 3 robbery.

Black Bart served four years at San Quentin and after release he was constantly shadowed by Wells Fargo detectives. In a letter to his wife he said he was tired of the attention, and disappeared after being last seen near Visalia on February 28, 1888. A distinctive feature of Black Bart was that he was consistently a gentleman, always polite and never using profanity. It might be said that he was a rare and exemplary professional in his business, living according to his values. His sense of mission will never be exactly known to us today, but Black Bart was somehow compelled to right some perceived wrong and, like most of us, he needed an income so Wells Fargo was a fitting opportunity.

Even in his risky occupation Black Bart remained kind and harmless, other than theft from a corporate entity of questionable kindness itself, it turns out. If he could act kindly in spite of living on the edge as he did, health care professionals such as us might consider him as a role model, although somewhat of a peculiar one. Somewhere along the line he must have had the parenting, mentorship, or experience that built his character of kindness, larcenous though it might have been. [Above book cover. Black Bart: Boulevardier Bandit. George Hoeper. Word Dancer Press, 1995]

 

Nine.

Jack Lapides. As we unearth stories of Michigan Urology, colorful anecdotes come to light and many involve Jack Lapides. The personal story of a patient who underwent a life-changing Lapides vesicostomy was told on these pages in July and that gentleman was ultimately laid to rest in a ceremony at Arlington in August. Another story from a former medical student was that of Jack teaching the students the art of cystoscopy when he would ask the students to peer over his shoulder and look through the scope to describe what they saw.

It is said that Lapides sometimes mischievously disconnected the light source cord as someone leaned in to look and occasionally an uncertain student provided a fanciful description of the dark or black field. This may have been one origin of his Black Jack moniker, although just as likely it might have been related to the fear he struck among rookies in his expectation for high standards and excellence. Dr. Lapides’s conferences were legendary. He was exacting and tough, requiring that all presentations be stripped of jargon and abbreviations. The IVP, for example, was intravenous pyelogram. Conferences today are more causal. The tradition of teaching conferences persists, but on a larger canvas since Lapides’s days with 4-5 faculty, our scale having increased by a factor of 10. Just below is Thursday morning Grand Rounds. Further below is the Friday AM Mott imaging conference that follows a formal review of operations scheduled the following week. In both instances we have outgrown our rooms.

Yet another Lapides anecdote turned up last week when I was at the American College of Surgeons (ACS) meeting and spent an evening with Lou and Ginger Argenta (below: with Tony Atala of Wake Forest, in San Diego October, 2017).

Lou had been our plastic surgery head in my early years at Michigan and innovated, with Michael Morykwas at Wake Forest, the Vacuum-Assisted Closure (VAC) device, a paradigm-changing system to manage burns and wounds. For this he won the Jacobson Innovation Award from the ACS in 2016. Lou recalled how Jack Lapides, in his retirement years, took up welding and small engine repair, learning and teaching them at Washtenaw Community College. Jack kindly performed a welding repair on the broken bicycle of young Joey Argenta, and the work held up for years of further bicycle abuse.

Lapides stories will undoubtedly continue to emerge. The man and his work had a long reach.

 

Ten.
What really matters to us, to our patients, to our colleagues, to our community, and our 7 billion global brethren is a deep question usually lost in the daily hustle of life. Most people have roughly similar ideas about what matters, although each has a particular take on things. Donald Campbell, Charles de Nancrede, Charley Bolton, Jack Lapides, Dr. Doeg, CW Waddington, FDR, and Rockwell had their particular world views that shaped their legacies. All, no doubt, shared many of the things that mattered to them, although each likely ordered and interpreted those characteristics idiosyncratically, perhaps Black Bart most peculiarly.

It is no accident that the four essential freedoms that Roosevelt identified have a strong basis in health care. Freedom from want is most obviously tied into food security, but it could just as easily be interpreted as freedom from needs that rationally include shelter and health care. Freedom from fear was illustrated by Rockwell as a fear of illness, but safety and personal security could just as easily have been the visual that Rockwell used. Liberty in the political sense is not so far from liberty in its mobility sense. An authoritarian regime may enforce curfews or travel restrictions, just as health conditions restrict people from being out and about to participate fully in society. If governments are to promote life, liberty, and the pursuit of happiness, the four freedoms are essential.

Human values and role models are the factors that translate human beings into the superorganism of human civilization. Those factors can go the way of apoptosis or can epigenetically build a prosperous, just, beautiful, robust, and sustainable version of itself for the next generation.

[Autumn foliage, my neighborhood 2017]

 

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

Gratuitous thoughts for October, 2017

Matula Thoughts Oct 6, 2017

3855 words, 31 pictures

 

 

One.

Every business has its seasons and the fall is primetime for academic medicine and other occupations. While we are reluctant to see summer slip away, autumn brings excitement and new energy. Entering medical students accommodate to a new learning environment, seasoned students consider career selections and their Step 1 exam, and senior students are consumed with the residency match. [Above: first year medical students at lunch in July on their first day.] Similar anxieties play out for residents although the intensity and duration of years usually exceed those of medical school. Exams don’t go away in residency, for the residents and fellows contend with yearly in-service tests and ultimate board certification processes. New faculty undertake “on-boarding” processes as they step out into the mature and most demanding phases of their careers.

Faculty teach and mentor intensely in the autumn and show their academic stuff at professional meetings, all while fulfilling the 24/7 demands of healthcare. Many faculty also have deep research commitments that bear the intellectual fruit we expect will make tomorrow’s health care better than that of today. Faculty, too, contend with promotion expectations, board recertification examinations, and the insane administrative on-line mandatory expectations required of them. Somehow our faculty get all this done, and done very well in comparison to other medical schools and academic health centers.

The 24/7 health care cycle is relentless. Our Department of Urology provides care throughout 16 clinical sites and 9 surgical locations, held together by a first-rate administrative team with Malissa Eversole, Marleah Stickler, Kandy Buckland, Tammie Leckemby, and of course Sandy Heskett. Jack Cichon, with our inaugural Urology Chair Jim Montie, set the pace for this excellence. Monica Young leads the Call Center that, with our administrative staff, coordinated 42,041 clinic visits, with 12,639 new patients and 6,426 operative procedures for our clinical faculty last year. The UM health system, Michigan Medicine, is growing and changing our regional profile as well as the local environment “on the hill.” The lovely view seen below,  over open space created at the old Kresge Laboratory site, will disappear when a new patient tower assembles on this site.

 

Autumn academic meetings and the written medical literature that springs from them display much work from the faculty and alumni of the University of Michigan Medical School. Our Urology Department provides a heavy presence at all relevant urology professional meetings this season and contributes significantly to Michigan’s “academic product,” thus furthering the mission, vision, values, and strategy of Michigan Medicine. At this time of year amidst the dense shop-talk at professional meetings in medical specialty meetings, Michigan football talk enlivens conversations.

 

Two.

A field trip to Chelsea Milling Company last month showed us how another business stays ahead in challenging times. Autumn and winter are prime baking season, according to the company president Howdy Holmes, so Chelsea Milling’s products need to be well-stocked in grocery stores throughout 50 states and 32 other countries.

Chelsea Milling has weathered many changes in its competitive markets, making Jiffy Mix since 1930 with a dominating market share in muffin mixes and entering a busy season as we do. Our tour revealed constant innovation throughout Chelsea Milling in production, employee satisfaction, quality, safety, packaging, and distribution, with lessons for our work in Michigan Medicine. A strong workforce aligned around mission, vision, and values combined with enlightened leadership creates quality products, a pleasant workplace, stakeholder satisfaction, and a durable business. We found it all comes down to the team.

[Above: DAB, Paholo Barboglio-Romo, Lindsey Herrel, Courtney Shepard, Miriam Hadj-Moussa, Howdy Holmes. Below 2 pictures: first home game from Martin family seats.]

Sports metaphors work well in business and health care discussions. Belief in teams, mutual support, practiced fundamentals, creation of plays, discovering opportunities, striving for excellence, relishing victories, learning from defeats, while educating successors, are universal attributes of successful social endeavors. Michigan’s athletic teams provide life-changing environments for thousands of students each year, and these students will bring the skills, disciplines, habits, and leadership they learn from their sports to the teams of their ultimate careers. It is a happy accident that most modern universities incorporate athletic teams along with other performance arts such as music, theater, law, engineering, nursing, pharmacy, and health care. The Schembechlarian admonition to attend to “the team, the team, the team” pertains to nearly everything we do and teach at Michigan. Michigan football, however, is probably our university’s most universally-acknowledged product and it brings a shine to everything else on our campus, especially in winning seasons.

The Nesbit Alumni Society of our Urology Department links its yearly reunion to football games, this year coinciding with the victory of Air Force. Just as every profession has its rules and standards, each sport has its mores – its customs, practices, and values. Overarching the peculiarities of each sport, a sense of fair play transcends most activities, more so in college than professional sports. Fair play pertains in academic medicine as well, where each specialty and local medical center have their own cultural rules and expectations, but overarching expectations of fairness and integrity apply, thereby restricting discrimination, plagiarism, deceit, substandard work, and self-serving behavior. Breaches of trust are naturally inevitable in human society, especially when temptations are great, but this is where character is discovered. Intercollegiate sports and graduate medical residency training are excellent crucibles to discover and build character.

 

 

Three.

Residency training and intercollegiate sports share many features of education, coaching, and team-building. Visiting professorships to openly share best practices among “competing” centers, however, are strong traditions in chiefly in health care. Michigan’s former chair of Internal Medicine, Bill Kelly, urged his faculty to bring in thought-leaders and innovators to their divisions each year to speak and challenge residents, fellows, and faculty themselves. This added expense of multiple visiting professors is offset by robust clinical productivity by faculty and philanthropic gifts that put dollars on the table for this type of education.

Carl Olsson (below), former chair at Columbia, was visiting professor for us in late August, discussing “A new prostate cancer biopsy reporting system with prognostic potential.”

The Weisbach Lectureship in Prostate Oncology brought Peter Carroll, Chair of Urology at UCSF, to Ann Arbor in September to discuss “Active Surveillance for early stage prostate cancer; should we be expanding or restricting eligibility?” This lectureship (above) was started in 2002, in memory of Jerry Weisbach, pharmaceutical innovator and friend of the University of Michigan. [Below: Arul Chinnaiyan, Peter Carroll, and Ganesh Palapattu]

 

Four.

The Nesbit Alumni Society Reunion took place in mid-September. Initiated in 1972 by John Konnak in honor of Michigan’s first Urology Section Chief, the Society met for three days including the football contest with Air Force. John Konnak was a bedrock of the Michigan Urology training program when Ed McGuire came as section chief in 1983. John had an MD with AOA distinction from the University of Wisconsin, internship at Philadelphia General Hospital, U.S. Public Health Service experience in Arizona, and a year of surgical residency at UCLA’s Harbor General Hospital. He came to Ann Arbor to train with Nesbit and completed the residency program in 1969 under Jack Lapides. Every resident who trained under John benefited from his work ethic, humor, and high expectations. John was a respected citizen of the Medical School Community and was an early participant in Ethics Committee. The photo of the first adrenalectomy for Conn Syndrome standing with Dr. Conn and looking over Nesbit’s shoulder in the operating room is one of the great images of Michigan Urology.

John’s paper with Joe Cerny, “The surgical treatment of Cushing’s Syndrome,” remains a classic. [J. Urology 102:653, 1969] John passed away in 2011, but his wife Betty (below) remains an enduring supporter of our department and a steadfast presence at Nesbit meetings.

In two years (FY 2019) the Nesbit Society meeting will kick off the Centennial Year for Michigan Urology, if we view the initiation of world-class urology practice, education, and research with the arrival of Hugh Cabot in Ann Arbor in 1920. Cabot came from Boston where he had grown up, practiced surgery, and became a world-renown specialist in urology. His two-volume text, Modern Urology, helped define the field, previously known as genitourinary surgery. After overseas duty in WWI he was unchallenged by Boston’s private practice environment at the time, and came to Ann Arbor as chief of surgery in 1920, rapidly becoming dean of the University of Michigan Medical School (UMMS). His first 2 residents were Charles Huggins and Reed Nesbit. After Cabot was fired by the Regents in 1930 (“in the interests of greater harmony”) Nesbit became inaugural head of urology in the Surgery Department. Our Medical School had no dean for the next several years and was run by the school’s executive committee, although Cabot’s name and picture mysteriously remained on the Medical School class pictures through 1932, as noted here last month. Cabot completed his career at the Mayo Clinic, then led by his friend William Mayo (UMMS class of 1883), while Nesbit went on to grow the urologic clinical, educational, and research programs of the University of Michigan for the next 38 years. [McDougal et al. Urology 50:648, 1997] Although we could have been called the Cabot Society, Konnak’s choice of the Nesbit Society is the better fit.

 

Five.

Laymen often wonder what’s the big deal about medical societies. A friend often teases me about my professional meetings he calls “boondoggles.” My introduction to medical meetings began when I was a surgical resident at UCLA and faculty propped me up for presentations to local gatherings of the American College of Surgeons in San Diego, Napa, and Palm Springs. My awkward presentations at those times are pale by comparison to the poised and self-assured presentations our Michigan students and residents give today. For a beginner, the opportunity to get one’s head around a topic, present it to the “elders” in one’s field, and respond to questions is an important step in professional development.

My friend understands that healthcare is a social business. It takes teams, and today those teams are big. The knowledge and tools of healthcare evolved socially across generations through practice, discussion, observation, reasoning, experimentation, disappointment, success, insight, new ideas, criticism, refinement, innovation, and more discussion. These are the social tools of human civilization, working through mentorship, schools, guilds, organizations, and specialty practices. Urologic societies and academic departments came on the scene in the late 1800’s and continue to be the primary marketplaces for new ideas, leadership development, and talent spotting.

The University of Michigan’s North Campus Research Complex (above, Building 18) was the venue for the Nesbit academic sessions this year. This property was the site of the Warner-Lambert Park-Davis research center, later taken over by Pfizer. Lipitor was developed here. The company announced plans to vacate the property in 2002 and eventually sold it to UM, with clinical departments of the Medical School bearing a little under 80% of the costs, which for the purchase and deployment over 10 years was around $325 million. Since we assumed occupancy in 2010 most space is occupied, including significant urology presence with Dow Health Services Research Division, and laboratories and teams of Mark Day, Evan Keller, plus Arul Chinnaiyan and Scott Tomlins, of the Pathology Department. David Canter (below) presided over the space when it was Pfizer and recently our NCRC Executive Director.

 

Six.

The Nesbit scientific program was superb, organized by President Mike Kozminski and Secretary/Treasurer John Wei and implemented by our administrative team. The large space at NCRC dwarfed our 60 plus attendees, but was an hospitable environment. Bob Uzzo (below with former Cornell co-resident John Wei) from Fox Chase Cancer Center gave two world class talks.

Alumni networked with our present departmental faculty and trainees.

Jay Hollander, above with David Harold and Len Zuckerman (Nesbit classes 1984, 1978, & 1980), donated the famed Nesbit plaster prostate models in honor of Gary Wedemeyer, who attended with his wife Nola (below). Dave, gave our department some antique cystoscopes that we hope to place in a visible time capsule for our 2020 Urology centennial, along with the Nesbit models.

Mario Labardini (Nesbit, 1967) travelled from Texas and Tom Koyanagi (Nesbit 1970) from Japan gave excellent presentations, Mario (below) on an extraordinary historical intersex case and Tom on his innovative hypospadias operation that left a great mark in pediatric urology.

Below you see Tom between Adam Walker, new clinical assistant professor with our West Shore Urology group in Muskegon, and Ted Chang (Nesbit 1996), one of his residency teachers at Albany’s urology program under Barry Kogan (Nesbit 1981).

John Allen (below), from our Gastroenterology Section of Internal Medicine spoke on health care as a generality and a current political hot-button, discussing as either a basic human right or commodity. (Below)

The Ted and Cheng-Yang Chang (Nesbit 1996, 1967) along with Mike and Michael Kozminski (Nesbit 1989, 2016) were our two father-son Nesbit urology pairs in attendance (below).

Below you see residents and students admiring Nesbit’s teaching models and considering how different their learning of prostatic surgery is today with video systems, lasers, etc.

Dinner at Barton Hills amplified social opportunities with our treasured Nesbit alumni, Nesbit lecturers, faculty, residents, and families. The Koyanagi family (below: Tom, Kiyoko, Sachi) travelled from Sapporo, Japan.

The tailgate at Nub Turner’s GTH Products preceded a win over Air Force, 29 to 13. [Above: Ghislaine deRegge, friend of Mario Labardini with Mark and Carolyn McQuiggan at Barton Hills Country Club dinner; Below Rita Jen, Olivia Hollenbeck, Mr. Hollenbeck, Amy Luckenbaugh at tailgate]

[Above: flyover by Blue Angels, captured on Sony Alpha 9, 24-240 lens, thanks to CameraMall]

 

Seven.

Nationally and globally things are not quite so tidy and progressive as seems to be true for us momentarily in Ann Arbor. Absent any superheroes to rescue the world, my personal expectations are modest. Before you tag this edition of What’s New/Matula Thoughts as cynical, let’s consider that particular attitude and its linguistics. Cynicism is a natural human protective responsive, with virtues as well as its obvious dark side. The attitude is often instigated when people feel as though their actions cannot solve immediate problems, or if their beliefs or stories are incompatible with a larger narrative or expectations, predicaments such as George Orwell described in his later works, 1984 and Animal Farm. The theater of health care discussions in Congress is a real-world example. So too is the incompatibility of the pressing environmental deterioration of climate, air, water, and land in contrast to the much political rhetoric.

A brief article in The Lancet earlier this year, “Cynicism as a protective virtue”, caught my attention. This two-page paper of 10 paragraphs took me a few readings to fully appreciate, but it was worth the effort [Rose, Duschinsky, Macnaughton. The Lancet 389:693, 2017]. The authors acknowledge rampant cynicism in the healthcare workforce is a response to the subjugation of individual agency of clinicians to care for their patients to larger forces. These externalities to the doctor-patient relationship include mandated work-flow systems, revenue generation, service metrics, and abstracted audits. Cynicism, the authors say, is “the immune response and not the disease.” As clinicians try to care for their patients they need to discover a different way to practice. “This discovery is the lived negotiation of the distance between policy and practice.” Raw and untampered cynicism, the authors note, is destructive, investing cynics in negative outcomes and leading to indifference, fatalism, and burnout. On the other hand, they suggest that tempered cynicism (e.g. wry cynicism or thoughtful cynicism, for example) can be a strategic virtue creating a protective critical distance between the cherished personal caring and professional values, that led most people into health care professions, apart from the deforming reality of healthcare organizations and public policies. Strategically “alloying” cynicism to a thoughtful attribute can carry clinicians from the dark side to the good side, if we may evoke a Star Wars metaphor. Alloyed cynicism thus can be a self-care strategy to regain composure, humor, clarity, resilience, and collegiality. This alloyed cynic can be an intellectual superhero in the daily professional struggle against corporate healthcare.

 

Eight.

Academic Medicine is a medical journal that most urologists don’t inspect routinely. An article earlier this year from the UCSF Psychiatry Department was titled “Why medical schools should embrace Wikipedia” and explains how the medical school offered fourth-year students a credit-bearing course to edit Wikipedia. [Azzam et al. Academic Medicine. 92:194, 2017] The outcome was that 43 students made 1,528 edits and the 43 articles have been viewed nearly 22 million times.

The article intrigued me as user and a believer in Wikipedia. I have always liked dictionaries and encyclopedias and treasure the authority of the great classics like Encyclopedia Britannica, Oxford English Dictionary, and Stedman’s Medical Dictionary. Rapid evolution of new information, limitations of print publication cycles, as well as the cost, storage, and rapid obsolescence made a Wikipedia-like product inevitable. The democratic nature of Wikipedia’s content limits and accentuates its authority. I occasionally get soft criticism from readers of Matula Thoughts/What’s New when I reference Wikipedia. Most people assume the classic dictionaries and encyclopedias to be more authoritative, and mostly they were. However, as a former editor for Stedman’s Medical Dictionary, I am still haunted by an error of my own in one edition. We are also aware that revisionist history, propaganda, and stereotype perpetuation existed in many authoritative definitions and narratives of the past. Although inaccurate and untruthful accounts can certainly enter Wikipedia, the crowd-sourcing nature of the readership provides a healthy mechanism for ultimate corroboration, correction, or rejection. Faculty member Khurshid Ghani, when he joined us, noticed that Wikipedia had no entry for Reed Nesbit, so he set to work to create one that still stands. We should have more interaction with Wikipedia, perhaps creating a dedicated urological section that might rightfully appropriate the name WikiLeaks.

 

Nine.

Health care worldwide needs superheroes, but for now we can only turn to comic books for inspiration. Superman, the first larger-than-life figure in my memory, was introduced with the inaugural issue of Action Comics, 1938. Superman is shown above with Prankster who had no actual super powers, but used pranks and jokes to commit crimes and foil superman. [Action Comics 1 (77) October, 1944. Cover artist Wayne Boring.] This is ancient ploy was revisited in a book by Paul Woodruff called The Ajax Dilemma: Justice, Fairness, and Rewards [Oxford Press, 2011]. Ajax, the superman of his Greek army, legend tells, was superseded for ultimate honors by King Agamemnon in favor of Odysseus who used clever tricks (e.g. the Trojan Horse) to win the day and capture Troy. The rejection drove Ajax, “the soldier’s soldier,” to self-destructive cynicism and insanity. The actual superheroes in my adult life are more in the mold of Odysseus as a great intellect and leader; Lincoln, Churchill, Eisenhower, E.O. Wilson, and Don Coffey to name a few. The last two, as great scientists transcend science as humanistic thought-leaders. Lacking any superheroes as of today in health care, I guess it’s up to us to make things better.

Argus, a lesser-known superhero in DC Comics, first appeared in 1993. This character was named after the many-eyed giant of Greek Mythology. The “eyes of Argus” was an expression that conveyed the idea that one was always under scrutiny in the real world as in the mythological world. That is, if your integrity and character waivered at any moment, to know that society was watching you, just as Argus watched his fellow mythological superheroes. Argus Panoptes, the giant of 100 eyes, was always on the alert because he could let many of his eyes sleep at any time, but the rest were wide open. Argus was the servant of Hera and she commemorated him in the peacock’s tail. [Below, Indian peacock, Wikipedia.] Argus persists as a name in a number of reptile species with eye-like patterns and it was once a popular name for newspapers. Wiki comes from a Hawaiian term for “quick.” Perhaps the better term for Wikipedia would be Arguspedia or the Argus Compendium.

 

Ten.

Cynics might say that nothing is new under the sun, a statement discounting both the promise of innovation and the value of history. It’s hard, for example, to reconcile that statement with photography where the technology has changed drastically. For me the shift from negative and slides to digital had the greatest impact. It was midway through 2006 when I belated entered the digital world. All my pictures up to then are in boxes of negatives, slides, and prints in the office and at home, impossible to totally reconcile in terms of inspection and conversion. Innovation is relentless and the century and a half since the daguerreotype has seen innumerable changes in equipment and media. Ann Arbor has its own history of photography with the Argus Camera Company, founded here in 1936 as a subsidiary of the International Radio Corporation.

The Argus C3 rangefinder had a 27-year production run and was a best-selling camera of the time in the United States. Argus was sold to Sylvania in 1959 and then generally slipped from sight, with occasional and transient rebranded products. The Argus building complex was sold to the University of Michigan in 1963 and then again in 1983 to First Martin Corporation and the O’Neal Construction Company that reopened it in 1987 with an Argus Museum now on the second floor. The museum has been generously assembled and funded by Bill Martin and Joe O’Neal, principals of the companies.

The Argus Model A, created and introduced in Ann Arbor in 1936 is said to have been the first entirely American made 35 mm camera. Visually resembling the iconic Leica camera, the Model A cost $9.95 and 30,000 were sold in the first week according to The Argus Museum, a lovely exhibition area in the second-floor lobby of the Argus Building Complex. While there you can find some key UM entities including Michigan Radio, a research division of our Department of Radiation Therapy, and Michigan Create. The International Radio Company that made the Model A had been established here in 1931 by local businessmen under the lead of Charles Vershoor as a countermeasure to the Great Depression and the main early products were table and floor radios, the Kadette and the International, as well as the first mass-produced clock radio conversion kit for cars. With the success of the Model A the company changed its name to the International Research Corporation and in 1938 introduced the Model C camera. The C2 and C3 followed, the latter becoming known as The Brick. More than 2 million bricks were sold over the next 28 years.

A 1947 patent design for a twin-lens reflex was the basis for the Argoflex (Argoflex Seventy-five – above). The company name changed to International Industries Incorporated in 1941, Argus Incorporated in 1942, and Argus Camera in 1949. Production shifted to gunsights, tank periscopes, optical fire control devices, and electronic aircraft controls for WWII and the Korean War. A company newsletter, much like What’s New and Matula Thoughts achieved wide distribution in the 1950’s. Argus cameras were seen in movies including The Philadelphia Story (1940), Watch the Birdy (1950), Smokey and the Bandit (1977, 1980), and Harry Potter and the Sorcerer’s Stone (2001), as well as TV shows such as I Love Lucy, Gunsmoke, Leave it the Beaver, Gilligan’s Island, and Columbo. This rich trove of information comes from the Argus Museum, created around the Don Wallace collection by Bill Martin and Joe O’Neal, now managed by the Washtenaw County Historical Society.

 

Thanks for travelling through this month’s Matula Thoughts.  (Nesbit prostate models above)

 

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

Dancers and Michigan’s third century

Matula Thoughts Sept 1, 2017

3866 words
Dancers & Michigan’s third century

One.

Summertime play draws to an end and work comes into sharper focus this September, as the University of Michigan enters its third century. Medical education’s academic season has been well underway for 2 months as now the rest of the University of Michigan comes back on line and takes up the challenge of examining the world anew. Autumn academic meetings lie ahead and our faculty become traveling salesmen for their ideas. History has shown that many big ideas in urology have come from Michigan and we anticipate many more are ahead. Nesbit urology alumni will reconvene in Ann Arbor this month for a scientific meeting and see the Air Force Academy play Michigan in football. [Above: Jacob Lawrence. Play, 1999. © 2017 The Jacob and Gwendolyn Knight Lawrence Foundation, Seattle / Artists Rights Society (ARS), New York]

Individual views of the world are shaped by one’s lenses and frames, literally and figuratively. Bob Uzzo, our Nesbit visiting professor this month, once sent me a picture of surgical loupes belonging to legendary Michigan Urology alumni, Ralph Straffon and Bruce Stewart, who had brilliant careers at the Cleveland Clinic. Crisp block letters identify the owners so we know who owned each one, but can only guess how the world looked to either of them. These two remarkable Nesbit trainees impacted hundreds of thousands of patients, thousands of students, and hundreds of trainees. They added to the progress of urology worldwide and both men cherished their Michigan origins and wore their Block M’s proudly. I was lucky to have known Ralph, but never met Bruce. Their photographs hang on the wall outside my office [Above glasses; below Ralph in center, Bruce upper left]. David Miller profiled Ralph for the Bulletin of the American College of Surgeons. [Miller DC, Resnick MI: Ralph A. Straffon, MD, FACS, 1928-2004, remembered. Bull Am Coll Surg 89:32, 2004.]

 

Two.

Block M’s. Pictures on our walls bring the past into focus on a daily basis and as you walk from the Main Hospital to the Cancer Center you can see the Block M on the Medical School diplomas, first as a font and later as a symbol. The class of 1861 (below) is the first in the lineup. No pictures of previous classes, going back to our origin in 1850, seem to exist. (A fire in 1911 destroyed the Medical School building with some of the original early pictures.) In 1864 an M-font vaguely resembling a block M is evident in the word “Michigan.” The first typical Block M (with serifs) appears in letters in the picture title, Departments of Medicine and Surgery in 1881. This occurs again in the text of 1883 and 1884, but is gone in 1885. Note that 1883 has 2 class pictures, the additional one being an informal one with the entire class sitting together. That additional picture was given by 1883 class member W.F. Mills to classmate William Mayo years later, in 1936.

The Block M became a deliberate symbol or logo in the Medical School 1923 class picture, with 29 faculty portraits contained within an M outline (below). Three other faculty (President Burton, Emeritus President Hutchins, and Hugh Cabot who was simultaneously dean, chief of surgery, and solitary urologist) share space outside the M shape and under the center.

The Block M tracing features faint extensions at the bottoms of the letter, called serifs, with squared edges as “blockish” as the M itself. Additional “side” serifs adorn the top outside portions of the vertical limbs of the letter. This style of serif is called a square or slab serif and it continued in subsequent class pictures, although 1928 and 1929 offered oblique views of the Block M. The frontal view was restored in 1930, the year Cabot was fired by the regents (February 11). The 1931 picture was significant for urology including both Cabot and his former trainee Reed Nesbit, the sudden head of urology. Curiously, Cabot’s picture remained even in the 1932 picture. His firing left the Medical School without a dean until 1935 when Albert Furstenberg was appointed. Block M with serifs continued through 1944, although with minor variations including one oblique reversion in 1935. Two 1943 class pictures feature separate classes, reflecting the intensified medical education during the war effort. The 1945 Block M has short and thin slab serifs.

 

Three.

A 22-year run of Block M’s with serifs ended in 1946 when the shape simplified to a simple, unadorned Block M outline, sans serifs, containing 33 faculty including Nesbit within the logo.

No 1947 picture is present on the wall. A Block M with serifs returns in 1948. The 1949 picture has no Block M insignia, font, or outline whatsoever. Dean Furstenberg is present and the faculty include Nesbit now with some gray hair. A variant Block M with serifs is present in 1950 and 1951, and now the dean’s name is spelled “Furstenburg.” A sans-serif Block M outline reappears in 1952 including Nesbit again. The traditional Block M outline with serifs is restored in 1953, 1954 (the dean is back to Furstenberg), and 1955. The UMMS lists Albert Carl Furstenberg as dean 1935-59, so the variable spelling is odd. Interestingly, from the urology perspective, junior faculty member Bill Baum, is present in 1953 and again in 1954 then with Jack Lapides. Narrow and tall serifs adorn the Block M outline in 1956 with “Furstenburg” again, but the 1957 picture oscillates back to a sans-serif Block M with Furstenberg and faculty again in the M-shape outline. Serifs returned in 1958. Lapides represented the Section of Urology on his own in 1957 and 1958.

The Block M outline vanished in 1959, replaced by a small filled-in Block M logo over the year. This unusual picture shows no faculty except for President Hatcher and Dean Furstenberg among the medical students. The 1960 picture has a sans-serif Block M symbol, but as in the previous year no pictures within the logo. Nesbit returned that year among 26 faculty shown with the class, plus the university president, Dean Furstenberg, emeritus dean, 2 assistant deans, and one administrator. A solid filled-in black Block M logo is present in 1961, but the picture contains no faculty. Redundantly, that year, the class officer pictures show those students a second time. The same format repeats in 1962. Faculty return to the picture in 1963 but only 42 (presumably only senior ones) plus a non-faculty administrator within a Block M sans-serif, that repeats in 1964 with faulty including Nesbit. That pattern persists in 1965 with 27 faculty including 2 “class mentors” and some chairs. Also present are President Hatcher, the hospital administrator, and an assistant administrator. Nesbit is missing again.

Since 1966 each picture features a fairly typical Block M outline with slab serifs and faculty embedded the letter. Nesbit was back in ’66 but looks older and returns in 1967 for his last picture, gone finally in 1968, the year of his retirement. Lapides appears as section head of urology in 1969, but isn’t pictured again. The picture format has remained relatively stable since then, although as faculty grew to over 2500 by now, general faculty pictures were replaced by dean’s office faculty and chairs.

With the recent expansion of Michigan Medicine’s footprint and regional affiliations the Block M has undergone tweaking and constraints, reportedly to maximize its effect. Articles in the Michigan Daily by Austen Hufford (October 20, 2014) and Tim Cohn (March 28, 2017) explain the evolution of the maize-colored Block M from an 1888 football team photo and 1891 team uniforms to its present proxy for the larger University of Michigan. Michigan’s branding blossomed under athletic director Don Canham, as reported by the late great sports writer Frank Deford in Sports Illustrated in 1975. [Deford. No death for a salesman. Sports Illustrated. July 28, 1975]

[Above: instructions on use of the University of Michigan logo]

 

Four.

West Shore Urology. The Block M will extend to Muskegon and the West Shore Urology (WSU) practice this fall. Started in 1972 by Thomas Stone (retired in 2000) the practice now consists of Kevin Stone (son of Thomas), Joe Salisz, Jennifer Phelps, Brian Stork, and Adam Walker (in Alaska at the time of picture) who join us as Clinical Assistant Professors of Urology as their practice becomes a UM ambulatory care unit. WSU is a high-level practice with philosophical commonalities to UM and strong ties, particularly through the Michigan Urological Surgical Improvement Collaborative (MUSIC) run by David Miller and now Khurshid Ghani. We will learn how to collaborate at a significant distance. Lisa Thurman is the PA at WSU.

Joe, Brian, and Kevin trained at Beaumont, and Jessica at Henry Ford, institutions populated by Nesbit alumni including Ananias Diokno, Jay Hollander, Evan Kass, and Hans Stricker. Adam Walker trained with Nesbit alumnus Barry Kogan at Albany Medical Center. Adam, a Hillsdale College and University of Minnesota Medical School graduate, comes from Elmendorf-Richardson Joint Base in Alaska where he was Chief of Urology, a position formerly held by our Nesbit alumnus David Bomalaski. Dave, by the way, remains in practice in Anchorage as the only pediatric urologist in the state and in the entire Indian Health Services system. The WSU team staffs Hackley Hospital, Mercy General Health Partners, Gerber Hospital in Fremont, North Ottawa Community Hospital, and Muskegon Surgical Center. Their diverse skills and perspectives will enlarge our Department.

 

Five.

American artist Jacob Lawrence (1917-2000) was born 100 years ago (September 7). I first saw his work at the Phillips Collection in Washington, DC when in town for a meeting of the American Academy of Pediatrics Section on Urology. His 60-panel Migration Series, funded by the Works Progress Administration and completed in 1941, illustrated the story of the Great African-American Migration from the rural south to the urban north, beginning around 1910. Lawrence worked on the paintings more or less simultaneously to maintain a uniform stylistic sense, he called “dynamic cubism” and considered the work a unity rather than 60 individual paintings.

Fortune Magazine in 1941 published 26 paintings from the series. Ironically, the paintings are now divided between the Phillips Collection (odd-numbered), where I first saw Lawrence’s work, and the Museum of Modern Art in New York (even-numbered). In 2015 and 2016 the split collections were merged and exhibited as a complete set at each museum before returning to their previous homes. Three-dimensional reconstructions of this work form the introduction to the current Kathryn Bigelow film, Detroit. Lawrence told other stories in collections of paintings featuring Harriet Tubman, Frederick Douglass, John Brown, Toussaint L’Ouverture, and a set called The Builders Series.

[Photograph above: Jacob Lawrence, Peter A. Juley & Son Collection, Smithsonian American Art Museum J0001840. Original photograph by Geoffery Clements. Image courtesy of the American Federation of Arts records, 1895-1993 in the Archives of American Art, Smithsonian Institution. Below: John Brown as surveyor in The John Brown Series. © The Jacob and Gwendolyn Knight Lawrence Foundation]

 

Six.

Throughout most of human history health care was delivered by single individuals. Presumably starting out in clans and villages our predecessors in healthcare accumulated healing skills through practice of their arts. Midwives, shamen, herbalists, and the stone doctors mentioned by Hippocrates, specialized in skills. By mid-16th century specialists such as internists, barber-surgeons, and apothecaries were assembling in guilds. Subspecialization reached full display in mid-20th century, when most physicians sought special knowledge and skills based on organ systems, technologies, age groups, or sites of service such as emergency departments and ICUs. The career-defining piece of medical education shifted from medical schools to graduate medical education (residency training) now involving over 100 areas of focused practice, often taking as much time or more than medical school years. The downside of this plethora of specialties is a complex clinical terrain in which patients shuffle among specialists, responsibility is diffuse, hand-offs incur errors, patient satisfaction sinks, and costs soar.

It is natural that arborization of medical skills is countered by nostalgia for omnipotent physicians to take complete care of patients or at least “quarterback” the specialists. This notion of primary care vs. specialty care, however, is more a political distinction than an epistemological one. The idea that everyone should have a “primary” caregiver who will identify specific needs for “specialty care” in patients and make proper referrals (administratively approved by third parties) is attractive, but the reality is that many, if not most, patients needing something specific, identify that need themselves – broken bones, eye trouble, urinary infection, chest pain, etc. – and find care through an emergency department or direct referral to specialists. The modern dilemma of coordinating health care teams, epistemologies, funding mechanisms, education, research, public policies, markets, while maintaining equity is acute. This is the arena of health services research.

Our Dow Health Services Research Symposium is in a bye year, and will hold its 4th meeting in 2018, highlighting our best faculty and resident work and bringing notable young urologists from across the country to similarly showcase their academic wares. Above you see last year’s symposium where Chad Ellimoottil, Michigan Urology Assistant Professor, highlighted Avedis Donabedian, Michigan’s great founder of health services. I first heard Donabedian’s name through Jim Montie and David Miller who gave me the classic 1966 paper. [see Berwick and Fox, Milbank Quarterly 94: 237, 2016] Health service researchers frame clinical problems one way, urologists view them another way, patients have personal points of view, and family members have their own perspectives. All those visions matter, although that of the patient usually dominates for it is on the patient’s behalf that society marshals the resources of treatment.

 

Seven.

Responding to thoughts on secularism and sectarianism in these pages last month, my friend David Featherman – Professor Emeritus of Sociology, Psychology, and Population Studies and former Director of Michigan’s Institute for Social Research – took my comments to a deeper and more significant level, writing:

“Of course, the most common antonym of secular is sacred, although partisan or sectarian appear in some thesaurus sources, as you note. As a general mental puzzle for me these days I wonder if our secular society, for all its other benefits you note, has verged, in some instances or quarters into sectarianism – in the sense of illiberal, intolerant and perhaps even partisan … Certainly, what I point to is not religious sectarianism, although one might admit to a quasi-religious sectarianism …
Those docs-to-be [referring to the White Coat Ceremony], touching patients with their stethoscopes, strike me as potentially moving beyond the non-spiritual or secular into a realm of human interaction not entirely bound by rationality and reason or lacking in the stuff of human compassion or failing to acknowledge something like a ‘mystery’ in life and death … What strikes me as I write is that the white coat might symbolize one of the larger dilemmas of our time, namely, how to draw upon the sacred and the secular as complementary resources …
If zealots … only can see opposition, in archly incommensurate terms, we shall fail to build that cosmopolitan, tolerant but at the same time spiritually, morally, and ethically grounded world. Without the latter resources, an exclusively secular world of wholly liberated individuals can easily lose its bearings to entropy. Those young docs in training have extraordinary opportunity to teach us how to achieve a more complementary cosmopolitanism, day by day, patient by patient.”

David’s point, in a nutshell, seems to be that we cannot isolate secular professionalism of health care from a notion of the sacredness of human life and morality. This veneration transcends specific religions, deities, or other schools of belief, but it is a sacredness that the secular world needs to contain, even if this seems somewhat paradoxical. Lacking this, Professor Featherman rightly professes, a secular society and its cosmopolitan world of nations, religions, markets, universities, politics, and corporations, spin out centrifugally and dissolve into entropy.

 

Eight.

The eclipse last month brought a moment of cosmic uncertainty to the uninformed, although astronomers profess that the occurrence was totally predictable and certain, occurring completely over the continental United States. [Above picture from Hinode Solar Observatory Satellite JAXA/NASA. August 21, 2017.] My colleague Philip Ransley, who has split his career between pediatric urology and chasing the moon’s shadow, gave a lovely talk on lunar eclipses when he received the Pediatric Urology Medal from the American Academy of Pediatrics in 2002:

“There is a beautiful rhythm in moonrise and rhythm in sunset. But there is nothing to compare with standing high on the Bolivian Altiplano in the center of the cone of the moon’s shadow with sunset all around and the eclipsed sun hanging in the darkness. Here, the majestic progression of time is played out before your eyes. An eclipse is quite an extraordinary coincidence. The sun is 400 times larger than the moon. By coincidence it is exactly 400 times farther away, and so the moon just covers the sun. But beware! We live in special times. The moon is moving away from us by a few centimeters each year. That is more than a meter further away than it was when I started coming to AAP meetings, and after only 2,000 million more annual meetings the moon will have moved so far away it can no longer cover the sun.” [Ransley. Chasing the moon’s shadow. J. Urol 168:1671, 2002]

This geometric coincidence is a cosmic rarity of time and space. Science writer George Musser wrote: “In all the hundreds of billions of our Milky Way galaxy, few, if any, are likely to produce total eclipses like ours.” [NYT Aug 6, 2017. The great American eclipse of 2017.] Rare moments of eclipses once terrified our ancestors, jeopardizing their routine predictability of day and night. Mark Twain’s 1889 book, A Connecticut Yankee in King Arthur’s Court, tells of an engineer who, after a head injury, finds himself in 6th century England and convinces people he is a magician by using the tricks of modern knowledge, such as predicting the eclipse of 528. Edmund Halley in 1691 applied the name Saros, from an 11th century Byzantine lexicon, to the eclipse cycle of 6585.3211 days that predicts when nearly identical eclipses occur. Halley’s appropriation of the name may be technically inaccurate with respect to the number, but it has endured. The celestial dance of Sun and Moon, from our point of view as Earthly audience, produces spectacular moments of eclipse when the two bodies seem to become one. Knowledge transforms those coincidences from terrifying episodes of uncertainty to predictable occasions of beauty. [Above: lunar eclipse diagram, Tom Ruen. Wikimedia, public domain.]

 

Nine.

A transatlantic collaboration between Ann Arbor and Copenhagen, initiated 23 years ago by Dana Ohl and Jens Sønksen (above) culminated 2 years ago in Denmark with a conference branded as CopMich, and reconvened here in Michigan for 3 days last month with 50 excellent talks from junior and senior faculty of both institutions, plus our residents and fellows (below). Dana and Jens plan to continue this on a 2-year cycle, offset with our biennial Dow Health Services Research meeting. Our Andrology Division under Dana Ohl has grown to 4 clinicians including Jim Dupree, Miriam Hadj-Moussa, and Susanne Quallich Ph.D. (nursing). Jens spent a year working with Dana in 1994 and has maintained close ties with Michigan Urology. Our new residents room is named for Jens.

CopMich has expanded beyond andrology to include stone disease, voiding dysfunction, pelvic pain, and robotic oncology surgery with speakers from our department and the Department of Urology at Herlev and Gentofte Hospital and the University of Copenhagen, where Jens is Professor and Chair. Guest speakers were Manoj Monga, Director of the Stevan Streem Center for Endourology and Stone Disease at the Cleveland Clinic as well as the American Urological Association Secretary, and Chris Chapple of the Royal Hallamshire Hospital in Sheffield UK and Secretary General of the European Association of Urology. [Below: Manoj and Chris]

Michigan’s own celebrities spoke at CopMich program as well. Ed McGuire, emeritus professor and chief of urology (1983-92) and John DeLancey Professor of OBGYN have virtually defined the intellectual and clinical terrain of female pelvic medicine and pelvic floor neuroanatomy. Dee Fenner, like John, is also a joint faculty member of Urology and esteemed throughout the world. [Below: McGuire, Fenner, DeLancey]

The meeting, offering 15.75 CME credits, was underwritten by both academic units as well as ReproUnion and the Coloplast Corporation. Stig Jørgensen (below) represented ReproUnion and gave an excellent presentation on its funding mechanisms in Europe.

The Danish contingent was superb (partial contingent below) and, after all, there is nothing like a Dane (apologies to Rogers, Hammerstein, and South Pacific).

 

Ten.

My daughter Emily is an Irish literature scholar, so any mention of WB Yeats is likely to catch my attention, especially in an administrative meeting. This happened recently when Marschall Runge brought Dr. Fionnuala Walsh, former senior vice president of global quality at Lilly, to his regular meeting with the department chairs to describe the company’s quality journey to operational excellence. Her presentation perked me up with a reference to Yeats, specifically the last 2 lines in his 1928 poem Among School Children:

“O body swayed to music, O brightening glance,
How can we know the dancer from the dance?”

Novices like me can hardly guess exactly what Yeats had in mind with this thought, beyond the obvious conflation of performer and performance, but that’s the beauty of art in that one’s personal experience as the viewer or reader is where meaning is ultimately ascertained. Yeats also reflected on dance in other works, notably Sweet Dancer, a poem begging the audience to let the dancer “finish her dance.” [EC Bloom. W.B. Yeats’s Radiogenic Poetry in The Wireless Past. Oxford University Press. 2016] Sweet Dancer was first published as a radio play in 1937, a time described as Yeats’ “second puberty.” Yeats’s life, like most, intersected with urology and for him the coincidence most famously was his Steinach operation in 1934. [MA Kozminski, DAB. J Urol. 187:1130, 2012]

That metaphor of unity between art and artist surfaced again recently in a JAMA article by Kimberly Myers called The Paradox of Mindfulness: Seamus Heaney’s “St Kevin and the Blackbird.” [JAMA. A Piece of My Mind. 318:427, 2017] Myers reflected on the challenging impact of fatigue on a person’s attentiveness to responsibility and compassion and links the allegory of the medieval monk to the modern health care provider.
“One might say of the physician what St Anthony says of the monk: ‘The prayer of the monk is not perfect until he no longer recognizes himself or the fact that he is praying.’ … commitment to patient-centered medicine is noble, and it is arduous. And, as is true with any other clinical skill, perhaps it is only with years of practice and continual commitment to being one’s most authentic self in the work he is called to do that it becomes second nature, part of his very body, blood, and bones. Perhaps we are indeed most mindful when we are least aware of being mindful – to borrow a beautiful phrase from another Irish Nobel laureate, W.B. Yeats, when we no longer ‘know the dancer from the dance.’”

This idea brings me back to last month’s reflection on performance and the aspiration of going beyond mere competence to achieve excellence in one’s work. As medical faculty perform the work and study of health care while educating their successors, the moments of our performances are quantum bits of education for those who learn from us. Our best clinical and academic performances can inspire a future physician for a lifetime.

When we fall short we hope our observers have compassion for our human frailty, but that they are challenged to surpass us in their work. The extraordinary emergence, when a dancer achieves unity with a dance, is the very art of medicine that glues us together and inspires those who follow, now in the third century of the University of Michigan.

 

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

Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

Ideas and evidence, that is information indicating whether ideas or propositions are true, have been assembling at increasing rates over the past dozen millennia of human progress and Michelangelo’s Hand of God, Creation of Adam illustrates this concept beautifully, with the sagittal brain embodying mankind’s divine creative spark (Sistine Chapel fresco. c. 1511). [See Meshberger in JAMA. 264;1837, 1990] The University of Michigan has been a significant player for the past 2 centuries of that narrative. The university launched its bicentennial celebration last month, the Medical School had its 150th anniversary (sesquicentennial) 17 years ago, and in a few years the Urology Department will have its own centennial. These are not just self-congratulatory moments, but worthy celebrations given the impact of each of these three entities.

Long preceding our particular institution, universities began in medieval Europe as ecclesiastical places of learning, teaching, and study. Mostly shedding their sectarian roots over ensuing centuries universities became, in turn, technical schools, research centers, professional schools, and now giant enterprises of academia that also aggregate sophisticated athletic teams, musical societies, technology transfer businesses, and health systems. Most fundamentally, universities teach the next generation of society and address the world’s problems, generating new ideas and finding evidence to arbitrate which facts are true facts (in the terminology, once again, of Don Coffey). Universities are humanity’s best bet as honest brokers for tomorrow to teach our successors, build better societies, and pursue truth.

The University of Michigan, Medical School, and Urology Department have much to celebrate. The university originated as a small school in Detroit in 1817, the Medical School began in 1850 in an Ann Arbor classroom for 92 students, and Michigan Urology claims the 1920 arrival of Hugh Cabot (below) for its birth. Cabots were big figures in American medicine. Older cousin Arthur Tracey Cabot was one of America’s first genitourinary specialists, a founding member of the American Association of Genitourinary Surgeons, and Hugh’s brother Richard was a celebrated Boston internist. Hugh Cabot’s life was deeply impacted by military service in France during WWI. Returning to Boston in 1917 and unfulfilled in his private practice Cabot jumped at the chance to come to Michigan as fulltime surgery chair. He quickly became dean and in 1926 opened a modern hospital (1000 beds) with a multispecialty academic medical practice that defined 20th century medicine. Cabot’s first 2 urology trainees were Charles Huggins and Reed Nesbit. One would win a Nobel Prize and the other would shape the future of clinical and academic urology, in addition to succeeding Cabot as the urologist of record in Ann Arbor. [McDougal, Spence, Bloom, Uznis. Hugh Cabot. Urology. 50:648, 1997.]

 

Two.

Humans are natural historians and find it pleasing, useful, or sobering to rewind the past with anniversaries, centennials, or other markers that inform, inspire, or caution. For example, on today’s date in 1864 the Battle of the Wilderness began, a time when our Medical School was fairly new. The Civil War was much on the minds of Michigan medical students then, who would go off to fight for the north or south after graduation. Wilderness was the first battle of Lt. General Ulysses S. Grant’s 1864 Virginia Overland Campaign and, although tactically inconclusive with heavy losses on both sides, it thrust Grant into a national spotlight carrying him eventually into the White House.

The disabilities and deaths of the Civil War affected most people and families in the United States. Wars, with countless traumatic crises for soldiers and civilians, perversely stimulate improvements in healthcare. Infection and antisepsis were not understood in 1864 and even minor wounds from musket balls or the more accurate Minié ball, prominent in the Crimean War and American Civil War, became lethal long after the instant of injury because of subsequent sepsis. [Above: Battle of the Wilderness; near Todd’s Tavern, Orange County, Virginia, May 6, 1864. Imagined scene in the Civil War Print Series by Louis Kurz and Alexander Allison c. 1887.] Fifty years later antiseptic technique was commonplace and the surgical repertoire has expanded greatly when the U.S entered WWI, ridiculously claimed as “the war to end all war.” That horrendous conflict, however, not only gets repeated, but is ever more horrendous as technology expands weaponry. The experiences of medical personnel like Cabot in WWI translated into new knowledge, skills, specialties, and systems that refined health care in the world that followed, until the next wars.

 

Three.

Michigan’s Medical School had been open for 11 years when the Civil War began and the 2 years of lectures needed to produce an MD hadn’t changed much. Dogma filled the curriculum with little evidence for medical practice beyond personal experiences. The educational process was two-dimensional, consisting of faculty vs. students in classrooms. The lectures included concepts as ancient as Hippocratic and Galenic theories of little use in the real world. Medical students had only simplistic understanding of trauma based on gross anatomy and lacking any sense of physiology, infectious disease, or cellular response to injury. Trauma care was  mainly a matter of bandaging and crude orthopedic management. Anesthesia was rudimentary and surgical options beyond amputation were few. Most of what was taught in medical school as facts of the time would vanish under the scrutiny of science and emerging medical disciplines enlarged the curriculum in length and content. A UM hospital in 1869 (initially a dormitory for patients undergoing surgery in the medical school – shown below) opened a third dimension of inpatient clinical experience at bedsides as medical subspecialties began to form. Laboratory instruction, in emerging biosciences, provided a fourth dimension of medical education as a verifiable conceptual basis of health care was assembling.

Successive hospital iterations offered increasingly complex clinical experiences for medical students as well as patients and by the time of the 1910 Flexner report didactic classroom and laboratory experiences were equivalent to patient care experiences in the Medical School curriculum time and budget. An outpatient building in 1953 added a fifth dimension of ambulatory care that, in its own turn over the next 50 years, would exceed the scale of inpatient experience as medical specialties required more outpatient learning than bedside education. To maintain a clinical and scientific footprint for 700 medical students, 200 Ph.D. candidates, and 1100 residents and fellows, it became evident that a new dimension of statewide clinical opportunities and affiliations would be necessary. This has been happening over the past 15 years with Livonia, East Ann Arbor, Brighton, Northville,  a growing number of professional service agreements, and regional affiliations such as MidMichigan and MetroHealth that create opportunities for “population health management”, for the University of Michigan Health System (now Michigan Medicine) representing a sixth dimension of health care education. In many respects, this new paradigm is as big a leap into the future as that first university hospital was in 1869.

Just as during the Civil War, WW1, WW2, Korea, or Vietnam (on the minds of my school cohort), national and international conflicts will affect today’s medical students who are in jeopardy, after graduation, of being thrust into action using their newfound knowledge and skills in dire circumstances of armed conflict.

 

Four.

Part – whole dilemma. One difficulty in healthcare today is the matter of deploying specialties for the care of patients, while keeping the whole of the patient in perspective. The specialties formed as 20th century ideas and evidence enriched the practice of medicine and the curriculum of medical schools. New areas of focused practice led to a new layer of education for medical students after graduation, known as residency training. Parallel and complementary subspecialties and epistemologies similarly formed in the sister healthcare sciences, such as nursing, pharmacy, sociology, psychology public health, and engineering here at Michigan and around the world. In 1933 the American Board of Medical Specialties (ABMS) began to consolidate emerging medical specialties to assure the public of the training, qualifications, and professionalism of medical specialists. By 1984 Human Genetics was added to the specialty roster and 24 medical specialties were in play, as medical practice was becoming increasingly complex and fragmented. The ABMS then stopped adding new boards and chose to manage new areas of practice through subspecialty certification or joint certification of emerging areas of practice among specific boards. This seems to have worked out well so far with 150 areas of specialties and subspecialties now in practice. [Above: residents James Tracey, Parth Shah, and Rita Jen sorting out the work for the day after morning conference.]

No single person can successfully manage this proliferation of knowledge, skills, and technology on behalf of patients, so all parts of a given health care team must work together. The idea of a primary care gate-keeper is not working well as a coordinator of care or as a focal point to ration care. This is the “part-whole” dilemma; that is, how to reconcile the parts with the whole. We also see this socially and politically in managing a multicultural society. The same issue plays out in universities among competing and collaborating disciplines. Sociobiologist E.O. Wilson makes the case that interdisciplinarity is how the most important work for the human future is likely to take place. [EO Wilson. Consilience.] Interdisciplinarity in the Twentieth Century, the subtitle of a book by Harvey Graff, examines the part-whole relationship in universities, reviewed by Peled from McGill who concluded:

“Graff emphasizes the dynamic interdependence between knowledge, scientific epistemologies, and (inter) disciplinarity, while remaining wary of proposing any simple definitions. Instead, he stresses the importance of egalitarian exchanges and the role of history and the humanities in the study of interdisciplinarity. Although Undisciplining Knowledge provides insightful answers to largely unexplored questions, its main contribution lies in refining and reframing these questions for the benefit of historians of science and interdisciplinary researchers.” [Undisciplining Knowledge. Interdisciplinarity in the Twentieth Century. HJ Graff. Johns Hopkins University Press. 2015. Yael Peled. The domain of the disciples. Science. 350:168, 2015.]

Note the phrases “egalitarian exchanges” and “the role of history and the humanities.” Interdisciplinarity today may seem novel and groundbreaking, but it will likely transform into new fields of work and knowledge in the near future just as history shows in Michigan’s Medical School curriculum.

 

Five.

Evidence. The Stratton Brothers Trial began on this day in May, 1905, the first occasion for fingerprint evidence to obtain conviction in a murder trial. Alfred Stratton (born 1882) and his brother Albert (born 1884) were the first people convicted in for murder based on fingerprint evidence. The case, otherwise known as the Mask Murders (stocking-top masks left at the crime scene – below), the Deptford Murders (the location), or the Farrow Murders (the last name of the victims) initiated the interdisciplinarity of law and science (now, forensic science). A smudge on the empty cashbox looked suspicious to Detective Inspector Charles Collins, who wrapped up the box and took it to the newly established Fingerprinting Bureau at Scotland Yard. Alfred’s right thumb was a perfect match. The conviction ended up in execution of the brothers on May 23 at HM Prison, Wandsworth. Fingerprints are synonymous with unequivocal identification, truth for which no alternative explanation can be accepted. The truth matters for criminal law.

[Stratton masks. Courtesy of  The Line Up website. Article & image: Robert Walsh (http://www.the-line-up.com/).]

Tolerance of deliberate untruth corrodes a free society. We cherish free speech, but we cannot be indifference to deliberate falsehood. Just as evidence replaces dogma with verifiable information, deceitful claims must be challenged by testable facts.  Few have expanded on this topic with greater clarity than Harry Frankfurt, although it seems that misdirection of facts is becoming more prevalent. [Frankfurt. On Bullshit. Princeton University Press. 2005.] Propaganda, lies, and plagiarism fall are breeches of the important social norm of truth and should irritate us enough to call them out as learning opportunities so we can learn how to recognize them, understand how they corrode professionalism, use them as teaching opportunities, and reaffirm one’s own standards.

Not every crime has its fingerprints, but just as the internet offers plagiarists opportunity to harvest cyberspace, the internet gives readers strong investigative tools. Science magazine earlier this year dedicated an issue to the matter of how evidence should inform public policy and contained an introduction to the discussion called “A matter of fact” by David Malakoff [Science 355:563, 2017].

“This is a worrying time for those who believe government policies should be based on the best evidence. Pundits claim we’ve entered a postfactual era. Viral fake news stories spread alternative facts. On some issues, such as climate change and childhood vaccinations, many scientists worry that their hard-won research findings have lost sway with politicians and the public, and feel their veracity is under attack. Some are taking to the internet and even to the streets to speak up for evidence. But just how should evidence shape policy? And why does it sometimes lose out?”

What we take as facts or truth is susceptible to change or even error. In fact, evolution is built on error. Missense is the phenomenon in which a single nucleotide substitution (that is, a point mutation) changes the genetic code such that an amino acid is produced that is different than the one intended in the original genetic code. The ultimate protein built of the amino acids may be dysfunctional or nonfunctional as in the circumstance of sickle-cell disease where the hemoglobin beta change is changed from GAG to GTG. Random error, or perhaps “purposeful missense” from a creationistic point of view, is the mechanism of evolution and diversity.

 

Six.

We expect integrity in most transactions in society and we are justly offended when this expectation is not fulfilled. The privileges of professional occupations are based on their fulfillment of this public trust, and few professions are older or more essential than the health sciences. Error and imperfection represent the honest “missense”  of humanity’s work, but deliberate deceit is another story breaking a universal taboo.

Transgressions against the public trust are especially reviled in medicine and science. A spectrum of transgressions exists, from a casual moment of dishonesty all the way to fraud, theft, and other criminality. Plagiarism sits in the middle of the spectrum. Some plagiarism is merely poor scholarship, but most often plagiarism is out-right theft. Once someone falls into the plagiarism trap, it is difficult to distinguish among its variants. Self-plagiarism revolves around the repeating one’s own work, but representing it as new. Of course, we all repeat our own ideas and words over time, but if you write a book chapter the publisher may claim ownership of your words, so you must be careful not to repeat wholesale your own paragraphs or illustrations in later articles, especially if the perception is to be that the newer article is genuinely “up-to-date.” Still, this differs from the deceit of stealing someone else’s work.

Scientific misconduct with deliberate plagiarism, fabrication, and falsification of data is a big problem, not so much in scale and prevalence – for I believe we have only occasional bad actors in our midst – but more because of their effect of distorting truth and corroding the public trust as an article in Science by Jeffrey Morris last year examined. [Morris. After the fall. Science. 354:408, 2016.]

 

Seven.

Gaslighting. On May 4, 1944 MGM released a movie called Gaslight, starring Charles Boyer, Ingrid Bergman, Joseph Cotton, May Whitty, and Angela Lansbury. The story, based on a 1938 Patrick Hamilton play, concerns a woman whose husband manipulates her into believing she is insane in order to distract her from his criminal activities. One of his deceptions is causing gaslights to flicker, making his wife think her vision is unsteady. Fiction became reality as the gaslighting metaphor found use in everyday speech for forms of manipulation through denial, misdirection, contradiction, and outright deceit to delegitimize or destabilize a target. Florence Rush (1918-2008), an American social worker and feminist theorist, applied gaslighting in her work as a pioneer in studies on childhood sexual abuse. (She also introduced the concept of the sandwich generation.)

Plagiarism is one form of gaslighting, the deception being the authenticity of ideas, statements, or evidence. The assumption of truth is a bedrock expectation in healthcare. Once abused, trust is rightfully difficult to restore. For example, the trainee who fudges a laboratory report during rounds may momentarily escape with the untruth, but the intoxicating bad habit gets repeated and ultimately discovered. The same goes for plagiarism or overt research fraud, where the likelihood of discovery increases exponentially over time because perpetrators invariably repeat the offense and the longer the evidence sits in public space, the more likely it will be recognized for what it is.

Paul Simon’s 1986 song, All Around the World (The Myth of Fingerprints), challenged the metaphor of universal individuality with a great tune, but a cynical lyric. Steve Berlin of Los Lobos claimed that Simon never gave the band due credit for the music that they had previously created and played when helping Simon on the Graceland album. After the band saw “words and music by Paul Simon” on the album 6 months later, they contacted Simon who said “Sue me, see what happens.” They didn’t. [Chad Childers. Rock Cellar magazine. July 23, 2012.]

 

Eight.

Case reports. When I was medical student and resident, case reports were foundational parts of medical education, expanding the generalities of systemic and organ-based learning and offering personal stories of medical detective-work. Some case studies illuminated classic presentations of disease, others were exceptions that proved a rule, and some were exotic conditions that surprised and educated us. Case studies, coming from reputable sources, carried a sense of authenticity – they were accepted as true facts beginning with the earliest medical journals such as The Lancet. In time, with the emergence of technology, defined areas of study (the disciplines, departments, specialties) scientific method, and randomized controlled trials offered higher levels of rigor.

Case studies also provided many of us early chances to study an illuminating case, present at conferences, and even publish. Medical journals were once heavily dependent on case reports. Evolving technology added illuminating images to  20th century specialty journals. Whereas relatively few students and residents had access to million-dollar biologic labs or enormous data sets, any ambitious resident could find an interesting clinical story to expand upon and present.

In my early faculty years ivory towers began to sneer at case reports as journals marginalized and eliminated them. Hypothesis-driven research, sophisticated laboratory studies, clinical trials, and health services research dominate current medical journals. Electronic media by threatening the business plans of medical journals, have challenged their very purpose and identity, leading many publications to retreat to imagined core functions or pander to readership surveys that represent very weak science themselves.

A few journals have, however, maintained a place for single case stories or recently restored them. Case reports are a renewed feature in The Lancet. That journal and JAMA also embrace art, commentary, and relevant news that expand their interest for many readers. A recent paper in Academic Medicine, gives a strong argument for the educational value of case reports. [CD Packer, RB Katz, CL Iacopetti, JD Krimmel, MK Singh. A case suspended in time: the educational value of case reports. Academic Medicine. 92:152, 2017.]

I don’t think I’m so different than most of my colleagues in wanting medical journals that curate relevant facts and issues broadly. Anything related to sustenance of the human condition from our medical perspective should be fair game for our journals including new evidence, ideas, technologies, therapies, understanding of health and disease, environmental threats, controversies, health care economics, educational matters, medical humanities, and art. Focus and balance is necessary for editors and boards, but the strong journals of our times (The Lancet, JAMA, NEJM, or Science, for example) seem to get it pretty much right for their readerships.

 

Nine.

What Archie Cochrane learnt from a single case was the title of a recent article in The Lancet in its recurring section called “The art of medicine.” [Brian Hurwitz. The Lancet. 389:594-595, 2017.] The title of the article is ironic given that this Scottish physician (1919-1988) had extraordinary belief in randomized controlled trials that led to the Cochrane Library database of systematic reviews, The UK Cochrane Centre in Oxford, and the international Cochrane Collaboration. Yet, there in The Lancet, I found this article on what Archie learned from a single case. An illuminating single case can be a powerful tool, in medicine, in the broader scope of journalism, and in political speeches. Ronald Reagan was probably the first US president to use this tool in public addresses, as for example in the Pointe du Hoc speech in 40th year anniversary of D-Day at Normandy on June 6, 1944, when he alluded to stories of a leader (Lord Lovat), a bagpiper (Bill Millin), Canadians, Poles, US Army 2nd Ranger Battalion solders shooting ropes up over the cliff face, as well as Americans back home ringing the Liberty Bell in Philadelphia, going to church at 4 AM in Georgia, or praying on porches in Kansas. Reagan (and speechwriter Peggy Noonan) understood the specific instance of a particular story illuminates a much larger reality.

Scientific experimentation, including the randomized controlled trial, offers a high level of rigor and verifiability in accruing new knowledge, and largely has replaced stories of individual clinical experiences, however the work-in-progress of medical education shouldn’t be so highfalutin as to deny entirely the value of carefully-presented case studies

 

Ten.

New rules. Last month we held a retreat for faculty, residents, and advanced practice providers (pictured above and below at Michigan League). We heard ideas and facts from Vice Deans David Spahlinger and Carol Bradford, along with strategic plans from our divisions and associate chairs who oversee the components of our missions. It became clear that our department is nearly the right size for our mission and obligations, although we will need about 10 more FTEs over the next 3 years to reach and maintain that size. Mission, essential deliverable, markets, professionalism, and work-life balance were discussed. My term as chair will come to a close and we expect to announce a search committee this summer. Once replaced, I hope to remain on the faculty in a meaningful way for a few years just as did my predecessors Ed McGuire and Jim Montie. Jim, by the way, was unable to join us due to grandparenting privileges keeping him in Europe at the time, but he sent a short and inspiring video that explained how “culture eats strategy.” Jim’s ten pieces of advice, slightly rephrased below, for academic medicine ring very true.

a. Faculty have a higher purpose other than personal success; academic success is not a “win at all cost” endeavor.  Academic medicine is not the Hunger Games.
b. Expert and empathetic clinical care is the highest priority.
c. Urology’s culture is embraced and preserved by faculty and inculcated in fellows, residents, and staff.
d. We share respect for colleagues, fellows & residents, and staff.
e. Academic productivity is important.
f. Referring physicians are highly valued and respected.
g. Try to make UM better, even at some sacrifice.
h. A team is necessary and one with diverse thoughts and backgrounds is always better.
i. Salary should be sufficient to that ensure faculty are not being taken advantage of (actually or perceived).
j. Innovation is the lifeblood of outstanding academic medicine.


Jim called his list “Thoughts for living in Michigan Urology.” He also added a question for the new paradigm of Michigan Medicine: “How does Michigan Urology integrate UM affiliates into the Urology Department? Don’t wait for the institution to solve it. Decide what vision you have and move to implementing it. Get to know the people at these other hospitals and practices.”


These are our thoughts for May, a month in which the redbuds have been amazing in and around Ann Arbor.

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

March Thoughts

DAB What’s New March 3, 2017

March Thoughts

3741 words

Periodic explanation: What’s New, a weekly communication from the University of Michigan Department of Urology, is distributed most Fridays internally by email to faculty, residents, and staff dealing with specific personnel and programs of the department. On the first Friday of the month What’s New is more general in scope, “a professor’s personal perspective,” and is also distributed to alumni, and friends of the department. The website (blog) version is matulathoughts.org, archived since 2013.

 

the_victors_sheet_music

One.
Winter marches to a close this month and we perk up in anticipation of more temperate days, with spring in mind. The meteorological first day of spring was March 1st in the northern hemisphere, but the astronomical start of spring this year will be Monday, March 20. That day may not look quite like spring when you come into work or go home  in Ann Arbor, even considering the start of Daylight Savings Time on March 12. Just as likely you won’t notice any seasonal change in windowless clinics or operating rooms as you attend to the work at hand, but spring is here.

or

[March in Mott,  2012 – Kate Kraft & Matt Smith]

Named for Mars, the Roman god of war, March is the only month with a musical name, if you consider the genre of John Philip Sousa and the Michigan fight song. UM student Louis Elbel (1877-1959) composed Hail to the Victors in 1898 (sheet music shown at top) and copyrighted it the following year when The March King, Sousa, and his band performed it publicly. Marches, of course have a much older provenance, as the illusion to Mars suggests.

Originally timed to drum alone, military marches set the pace for foot soldiers. Brass instruments, commonplace inclusions by the 19th century, helped marches become entertainment. Mozart, Beethoven, Mahler, and other great composers wrote popular marches for the public, although marching armies still kept pace with music. Napoleon, allegedly, adopted a rapid tempo of 120 beats (steps) per minute so his armies could march faster than British and other foes. Today’s militaries no longer set operational pace to music, except in movies. Marches now include a range of musical technologies and are far more likely to be heard on college football fields than on battlefields. Marches entertain and inspire, and the Michigan Fight Song may well have echoed in quarterback Brady’s head during the Super Bowl drama last month, certainly as great an example of athletic bootstrapping as anyone can easily recall. [Below: Louis Elbel conducting in the Big House, 1958]

louis_elbel

Political marches are also part of humanity’s fabric and the recent March trilogy, a graphic memoir of John Lewis, is noteworthy. Written with Andrew Aydin and illustrated by Nate Powell, this was published between 2013 and 2016 and is an effective way of telling history to younger audiences, where it most matters. [Below: March Book One] Civil disobedience, inspired by Mohandas Gandhi, changed India in the first half of the 20th century and Martin Luther King, John Lewis, along with many others would similarly change the United States in the second half.

march

 

Two.
Technology drives the comforts and arts of modern life. No one can deny that planes, trains, automobiles, indoor plumbing, central heating, air conditioning, and Nike sportswear make work and life more comfortable and convenient than it was for our ancestors. Visual and auditory art, no less significantly, buttresses the human condition ever since the first cave dwelling paintings, sculptures, and musical instruments. Technology over the ensuing 40 or so millennia changed those and all other human arts.

cave_painting_l

[Lascaux, France cave painting 15,000-10,000 BC]

Art has particular value for us in health care education, clinical care, and research. Brain stimulation, through artistry of one sort or another, makes us attentive, provokes curiosity, facilitates learning, and stimulates creativity. When the brain is stimulated, questions are raised, nuances perceived, conflicts understood, elegance appreciated, boundaries erased, and truths discovered. For these reasons we add art to walls, humor to lectures, magazines to waiting rooms, and music to surgical suites. Art expands the imagination that fuels the missions of academic medicine and fulfillment in our greater lives. This is the reason for our Chang Lecture on Art and Medicine, to be held this year during the Ann Arbor Art Fairs (July 20, 2017). David Watts, San Francisco gastroenterologist and author, will be our speaker.

the-she-wolf

[Jackson Pollack, The She-Wolf 1943. MOMA, NY]
Anticipating that lecture I read Eric Kandel’s latest book, Reductionism in Art and Brain Science, Bridging the Two Cultures. A review in Science caught my attention and I ordered the book at Literati, our local bookstore. [Alva Noë. Scientist’s Guide to Modern Art. Science. 353:1215, 2016] Nobel Laureate Kandel draws on neurobiological work in sea slugs to understand more complex processes of human learning and memory and concludes that our brains process abstract (modern) art very differently than we process traditional figurative art. [Eric Kandel. Columbia University Press, 2016] Interestingly, Kandel dedicated the book to Lee Bollinger, former University of Michigan president.

 

Three.

his_masters_voice
Every generation has its own music and for mine the new genre of rock and roll on 45-RPM single play records was the baseline. [Above: Francis Barraud’s painting of his brother’s dog Nipper, 1898] Music is a story of technology and its recording formats have been contested since their start. Thomas Edison’s tinfoil sheets (1877) and later wax cylinder phonographs were early technologies, but flat discs proved more practical. Emile Berliner (1851-1929), German-born American inventor, patented the Gramophone in 1887 and marketed 5-inch discs. One of his earliest recording artists was Manhattan singer George Washington Johnson (1846-1914).

george_w-_johnson_1898

[Above and below: George W. Johnson and his 1897 Berliner Gramophone recording. Source: Wikipedia]

berlinerdisc1897

Nipper achieved lasting fame when English artist Francis Barraud painted his brother’s dog listening at the horn of a Gramophone in the winter of 1898 and Berliner took the image for the logo when he formed the Victor Talking Machine Company 1901.

Cylinder recording technology, however, held on for a time and transitioned from wax to celluloid Blue Amberol cylinders in 1912 with playtimes of nearly 5 minutes. The flat disc, however, was destined to dominate with shellac and 78-RPM as the material and play speed of choice. In 1929 Victor Talking Machine Company became RCA (Radio Corporation of America) Victor and would make the first 33 1/3-RPM Long Play (LP) records. Columbia’s 12-inch vinyl 33 ⅓ LPs in June 1948 were a step forward in fidelity and durability. RCA Victor released the first 7 inch 45-RPM vinyl single record in March, 1949.

jackie_brenston-1

No single record precisely demarcates the start of rock and roll, although one contender for priority was Rocket “88”, a song recorded in Memphis around this day in March, 1951 by Jackie Brenston and Ike Turner. Brenston was the saxophonist in Turner’s band, The Delta Cats. [Above: Turner and Brenston] The tune rocketed to number one on the Billboard R&B chart and the title referred to the Oldsmobile 88. Somehow the recording identity and profits went to Jackie, rather than Ike and his band, setting off a lifetime of grievance. A second version of the song was recorded a few months later by Bill Haley and The Saddlemen. Haley’s better-known recording, Rock Around the Clock, came out in 1955.

 

Four.

1949_oldsmobile_88

Olds 88, produced by GM from 1949 to 1999 (shown above) initially paired a Rocket V8 engine with the Futuramic B-body platform (full size rear-wheel drive). Cars like this offered more than just transportation and fueled the imagination of generations throughout the 20th century in the music of the times, drive-in movies and eateries, and springtime road trips. House designs changed accordingly to include garages, highways changed cities, shopping patterns altered, and cars became offices or homes for some people. Detroit was the epicenter of the automobile industry and became a microcosm for entertainment, the labor movement, civil rights, urban collapse, and suburban sprawl. A perceptive book on this aspect of Detroit by David Maraniss was brought to my attention by our thoughtful correspondent at Emory.

“The city itself is the main character in this urban biography, though its populace includes many larger-than-life figures – from car guy Henry Ford II to labor leader Walter Reuther; from music mogul Berry Gordy Jr. to the Reverend C.L. Franklin, the spectacular Aretha’s father – who take Detroit’s stage one after another and eventually fill it.

The chronology here covers eighteen months, from the fall of 1962 to the spring of 1964. Cars were selling at a record pace. Motown was rocking. Labor was strong. People were marching for freedom. The president was calling Detroit a “herald of hope.” It was a time of uncommon possibility and freedom when Detroit created wondrous and lasting things. But life can be luminescent when it is most vulnerable. There was a precarious balance during those crucial months between composition and decomposition, what the world gained and what a great city lost. Even then, some part of Detroit was dying, and that is where the story begins.” [Author’s introduction. Once in a Great City: A Detroit Story. Simon & Schuster. NY 2015.]

 

Five.
Marching and retreating. When I became chair in 2007 I thought I had a good sense of what the job entailed, having been “schooled” under great leaders like Bill Longmire in Surgery at UCLA, Joe Kaufman (Urology at UCLA), Ray Stutzman (Walter Reed), Ed McGuire (here at UM), and of course our inaugural urology department chair, Jim Montie. Still, I had some unease, given an abrupt transition, and thus invited myself to Chicago to visit Bob Flanigan of Loyola. Our former dean Allen Lichter and my fellow chair Karin Muraszko advised me that I still needed help and linked me to an advisor with experience in practically any problem in academic medicine. That was David Bachrach who, from day one and my first faculty retreat, has been has been a stalwart adviser for our urology department.

Our team has grown since then with a full time urology faculty cadre exceeding 40, 18 joint faculty, 15 adjunct, 30 residents and fellows, 16 advanced practice providers, 22 nurses, 29 MAs, 52 research staff, and 51 administrative staff. We conduct clinics at 12 sites, operate in 7 locations, and have 8 research laboratories, including those of our joint faculty. The Nesbit Society, numbering 324, is one of our key stakeholders. This is a lot of stuff to keep in play at any moment, and anticipating a change in departmental leadership it is wise to take stock of our position and lay out plans for the future. Whoever assumes the chair position will find strong divisions that thoroughly understand their needs, aspirations, and plans within our department. The chair stands on robust shoulders; in my case, Jim Montie had tee’d up the job superbly and I have had a lucky and fairly easy swing for my turn.

A retreat is the converse of a march. As an organizational technique retreats are occasions for conversation, teambuilding, and realignment. A retreat is a purposeful opportunity to take stock of one’s position and figure out the next steps. If an organization is doing well, a retreat can be a process to figure out how to keep doing well, or to improve a team’s position, in a changing environment. If the organization, army, or unit is stuck in the mire, a retreat is a chance to bootstrap out of the situation into a better one. Historically, that 19th century term means to lift yourself up by your own bootstraps, a phenomenon that is physically impossible. This useful hyperbole, an adynaton, was a metaphor of absurdity until modern technology made it a reality in today’s computer world where rebooting (as the term has become) is something we do often.

440px-muenchhausen_herrfurth_7_500x789

[Postcard, in a series by German illustrator Oskar Herrfurth (1862-1934), depicting Baron Munchausen pulling himself out of a mire by his own hair.]

 

Six.
Movies, more than most other art forms, reflect and change our view of reality and sense of meaning. The Star Wars franchise, a powerful example of imagination surpassing any initial expectations of success, has extended recently from popular culture into economic theory. Zachary Feinstein, professor of financial engineering at Washington University in St. Louis, drew on the saga to predict that the destruction of the Death Star would have triggered a calamitous galactic financial crisis. [Feinstein. It’s a trap: the Emperor Palpatine’s poison pill. December 1, 2015. https://arxiv.org/pdf/1511.09054.pdf%5D

In response to the Feinstein paper, The Economist magazine undertook a deep analysis of the first six episodes of the saga (prior to the most recent iteration, number 7) and came up with three “important lessons for residents of the Milky Way,” that are relevant for the real world.

• Lesson one: regarding the value of trade – the freer the better.
• Lesson two: although globalization (galacticization) is an economic boon, it presents all sorts of political challenges that are not easily managed.
• Lesson three: regarding career options in the era of artificial intelligence and robots, humans will “still labor at dangerous and unpleasant tasks” because of inequities in the galactic political system.

The Economist concluded: “Humans will work for a pittance, if necessary, to scrape by. This may lead them to the dark side. Worse, it might prompt inquisitive souls to ask what forces drive such an uneven distribution of wealth, turning them [the inquisitive souls] into those most dreaded of creatures: economists.” [The Economist. December 19, 2015. Free exchange: Wikinomics]

Further pan-galactic insights are found in the book, The World According to Star Wars, by Cass Sunstein. [Sunstein. HarperCollins Books, NY. 2016] The author offers two opening quotes. The first, by Yoda, is: “Difficult to see. Always in motion is the future.” The second, by UM alumnus Lawrence Kasdan is: “It’s the biggest adventure you can have, making up your own life, and it’s true for everybody. It’s infinite possibility.” These thoughts encompass the great intersection of reality and imagination. Expressed differently, this is the intersection of the gift of human self-determination (that aspiration of democracy) and Shannon’s number of human imaginative possibilities that exceeds any galactic scale. [Claude Shannon, another Michigan alumnus, was discussed on these pages on May 3, 2013.]

 

Seven.
Helmut Stern, friend and benefactor of the University of Michigan, passed away earlier this year. He was 97 when he died on January 21. Helmut encompassed that infinite possibility of self-determination better than most of us, and did it with unusual kindness, grace, and imagination. Born in Hanover, Germany in 1919, his outspoken nature had put the Nazis on his case when he was 18 years old and he immigrated to the United States in 1938, aided in getting a visa by his Uncle Oscar. Moving to Washington D.C. he found a job working at night and attended George Washington University by day. Helmut hoped to go to medical school and moved to Ann Arbor in 1942 where he took a job at Metrical Laboratories to earn a living, but his career plans changed after he came to own the company. He then started another company, Industrial Tectonics, Inc. (ITI) manufacturing ball bearings, and soon had plants and licensees around the world. Helmut’s business acumen was unusually sharp and his manufacturing footprint expanded. In 1981 he sold ITI to devote time to another company of his, Arcanum, with the hope of making clean-burning coal. Helmut was a community builder, mentoring many younger colleagues in business and organizational management. He funded efforts to advance voting in young people and initiatives to strengthen the local safety net for those less fortunate. Helmut was kind, curious, and generous, a Renaissance Intellectual in every sense of the term. His art collection, with a focus on African work, stimulated his imagination, and he gave much of it to the UM Art Museum. The effects of his philanthropy echo throughout our University and community today. Helmut and his wife Candis (to whom I owe thanks for these biographic notes) moved to Las Cruces, New Mexico in 2009, returning to Michigan every six months until 2013 and during those visits he and I sometimes had lunch and discussed things such as the biology of morality, politics, and art. When travel became too difficult for him, Las Cruces became his permanent and final home.

sterns-2012

[Former regent Julia Darlow with Candis and Helmut Stern at inauguration of Jim Stanley’s endowed professorship 2012.]

 

Eight.

metro

Michigan Medicine is the new name for the University of Michigan Health Care System and I first saw it in prominent display in Wyoming, Michigan when I visited MetroHealth, our new partner. This new name and relationship are part of a new chapter in the story of medicine at the University of Michigan, but it has been a natural and inevitable progression that began when a faculty house became a hospital on our campus in 1869. The hospital iterations thereafter grew quickly to match the expanding conceptual basis of healthcare, medical specialties, and graduate medical education training programs that became the career-defining part of medical education. An outpatient building in 1953 was evidence of the growing importance of ambulatory healthcare not just for clinical practice, but also in education and research. Satellite clinics, surgical suites, and professional service agreements with other healthcare organizations followed the ambulatory attention as the 20th century turned into the 21st. A significant relationship with MidMichigan Health in 2013 placed the Block M prominently in the “outstate” arena.

The ultimate justification for expansion of the UM clinical footprint is the need to maintain our educational and research programs. This justification was reflected in name of the first serious A3 I produced, that having been in the winter of 2012-2013. An A3 exercise (named for the size of the sheet of paper used in the Toyota Lean Process approach to problem-solving) is a way to tell a story or to define and solve a problem. I titled my A3: “Our clinical footprint is falling short of our needs and aspirations” and it took close to 40 drafts to complete. Those needs and aspirations comprise our mission and our expectation to be leaders and best. In that earlier part of the new century’s second decade, it seemed that healthcare economics, policy changes, and consolidation of competitors threatened to make UM too small to matter and we had to find a way to bootstrap ourselves out of a position that was becoming untenable. We seem to be on the right track now.

 

Nine.
Imagination and reality go back and forth. Last month we considered the Angelman story and, as I was thinking of other examples, Baron Munchausen came to mind. This fictional character (although modeled after a real person) was created by German writer, librarian, and eccentric scientist, Rudolf Erich Raspe. Born in Hanover March 1736 he became a versatile scholar and a zoological paper of his led to membership in London’s prestigious Royal Society. Raspe fled to England in 1775 due to financial improprieties, and continued his scholarly interests including the imaginative stories in The Surprising Adventures of Baron Munchausen, a novel that he began to write in Cornwall when he was assay-master and storekeeper at the Dolcoath mine in 1785. Around that time he also wrote books on geology and the history of art. He died in 1794.

The fictional baron continues to illuminate the world far beyond Raspe’s expectations. Munchausen syndrome is a disorder in which a person feigns disease for any number of reasons. In the urology world, the drug-seeker who comes to the Emergency Department with abdominal pain and bloody urine (a finger cut dipped into their urine sample usually does the trick) is a common experience for our residents and on-call faculty. Munchausen syndrome by proxy is an odd situation we sometimes encounter in pediatric urology wherein a parent or caregiver fabricates or induces a physical or mental health problem for a child or other person in their care, the usual motivation being that of attention or sympathy. The Munchausen trilemma is a thought experiment involving a decision among three equally unsatisfying options. The Munchausen number is a perfect digit-to-digit number, a natural number equivalent to the sum of its digits each raised to the power of its digits. This is also called a perfect digit-to-digit invariant, for example, 3435 = 3 to the third, plus 4 to the fourth, plus 3 to the third again, plus 5 to the fifth. (WordPress seems unfriendly to math notation). Van Berkel coined the term because each number is “raised up” by itself, in the Baron Munchausen tradition. [van Berkel, Daan. “On a curious property of 3435.” arXiv preprint arXiv:0911.3038,2009]

 

Ten.

A perfectly satisfying national healthcare policy is a Munchausen trilemma. Everyone wants availability, quality, and affordability of healthcare, but we cannot figure out how to provide all three simultaneously. The private sector is complex, with insurance and capitated systems such as Kaiser, working in tandem with various government iterations of Medicare. The VA and other federal or community systems, such as our Hamilton Federally Qualified Health Center (FQHC) or Rural Health Clinics (RHCs), serve a growing segment of the public. The FQHCs and RHCs have over 6,600 sites of care and serve 66,000,000 patients each year, while the VA has over 1,700 sites and serves nearly 9 million veterans per year. This aggregate population of 75,000,000 largely underserved patients in these publicly-funded facilities constitutes more than 23% of the United State’s population. [Thanks to Michael Giacalone, Jr. for much of this data.]

Governor Rick Snyder championed Medicaid Expansion in Michigan against the grain of his political affiliation. He must have believed that it was the right thing to do for the people of Michigan and, as an accountant at heart, he may have had an intuition that the expansion made economic sense. A paper in NEJM by our faculty colleague John Ayanian et al showed how the Healthy Michigan Plan covered over 600,000 mostly uninsured people defrayed a large economic load on the state, families, businesses, and health care providers. Additionally, the state government ended up with more than it paid out for the program, Michigan gained 30,000 jobs, giving its people $2.3 billion more to spend. Projections to 2021, even as the state cost-share increases, will continue to be positive. [Ayanian JZ, Ehrlich GM, Grimes DR, and Levy H. Economic Effects of Medicaid Expansion in Michigan. N Engl J Med 2017; 376:407-410]

ayanians
John Ayanian is the Alice Hamilton Professor of Medicine at UMMS and the Director of the UM Institute for Healthcare Policy and Innovation, where our Urology Department Dow Health Services Research (HSR) Division is located, with David Miller as its head. Alice Hamilton (1869-1970) was one of the most important UMMS graduates (1893). She went on to being a leader in the emerging fields of occupational health and toxicology and was the first woman on the faculty at Harvard Medical School. It’s appropriate to see her name celebrated by such a worthy colleague as John Ayanian. [Below: John & Ann Ayanian with Chad Ellimoottil at our Dow HSR Division reception 2016.]

————————————————————–

Thanks for reading Matula Thoughts, this March of 2017.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

734-232-4943

dabloom@umich.edu

 

February, Sunday feelings, and Monday facts

DAB What’s New February 3, 2017

February lows and highs; Sunday feelings, Monday facts
3916 words

 

icicle

One.
February is the nadir of winter as well as the shortest and most variable month, with average snowfalls of 13 inches, highs of 35℉, and lows of 20℉ in Ann Arbor (U.S. Climate Data. Wikipedia). Even though not quite the coldest month February seems the wintriest, lacking the enticements of December holidays and the exhilaration of January’s new year. This February, a regular one without the extra day, allows only 20 business days to pay the challenging bills of academic urology. Educational and research expenses always exceed their funding streams and require clinical and philanthropic dollars to maintain them.

korlebu

[Michigan team and the Korle-Bu and Military Hospital staff, Accra.]

Last month 3 faculty and 2 residents escaped Michigan winter for a week of operating and teaching in Ghana. Sue and the late Carl Van Appledorn initiated this yearly trip and other generous donors help offset its draw on clinical revenue. John Park, Casey Dauw, and our former faculty member Humphrey Atiemo (now Program Director at Henry Ford Hospital) accompanied by residents Yooni Yi (UM) and Dan Pucheril (HFH) spent a productive week in Accra. Casey led the team in performing the first successful percutaneous nephrolithotomy in that part of the world. The Korle-Bu Hospital, affiliated with the University of Ghana, is one of the largest teaching hospitals in Africa. John Park will give further details in an upcoming What’s New/Matula Thoughts.

casey-perc

[Casey at bat.]

Back here in the USA the economic side of health care is ambiguous. Governmental funding, public policy, regulation, corporatization of the clinical domain, market segmentation, and escalating costs in pharmacologic/technology industries are some factors in the turmoil. Most healthcare industries maintain the public trust and behave admirably in seeking profits and market share – we certainly see this in the companies with whom we deal such as Johnson & Johnson, Medtronic, Boston Scientific, Storz, etc.

A few egregious actors stand out. The Mylan company’s repackaging of a natural chemical (epinephrine, for which nature holds the patent) with a syringe and needle was a mildly clever gimmick, but creating a monopoly for this lifesaving device and raising the prices for a two-pack from $100 in 2007 to $608 in 2016 is greed beyond the bounds of public acceptance. Mylan’s half price “generic,” offered recently, is a pathetic peace-offering to the public – a generic of a generic is elementary Orwellian Newspeak. [Epinephrine auto-injectors for anaphylaxis. JAMA; 317:313, 2017.] Teva Pharmaceutical was another one of the six drug makers recently sued by 20 state lawmakers on price fixing. These two companies are the largest generic drug makers by market cap. (It must have been awkward for Mylan’s CEO Heather Bresch to justify EpiPen prices because of research and development expenses in testimony to the House Oversight and Government Reform Committee last October.) [M. Krey. Investor’s Business Daily. Mylan launches cheaper EpiPen generic amid drug pricing saga. 12/16/16.] Below: Table A from 10/5/16 letter from CMS Administrator Andrew Slavitt to Senator Ron Wyden regarding Medicaid and Medicare Part D Expenditures on EpiPen products.

table-epipen

 

search
Two.

Regulation for the public good is essential in a world economy of 7 billion people and GDP of $78 trillion. All businesses exist because of the public trust, going back to the early days of the limited-liability joint-stock company, a story explained in a book called The Company that Julian Wan gave me years ago [John Micklethwait & Adrian Woolridge. Modern Library, NY 2003.] Most US businesses understand their public responsibilities, but uncommon greedy actors erode public trust and diminish the standards for the rest.

Regulation is under attack. It is inevitable that government regulations dampen corporate bottom-lines and short-term economic growth, that is the nature of regulation, but few rational people can deny that serious regulation of highway traffic, airways, nuclear energy, banks, health care, etc. is in the public interest. Offensive governmental regulatory overreach is bound to happen in any complex bureaucracy and should be called out when discovered, but these instances hardly disprove the necessity for regulation by impartial public agencies and civil servants in a healthy democratic society.

By now, in February’s wintry days of cold and snow, the EpiPen story is old news, but we hope that the protective regulatory functions of governmental regulation do not get snowed over or subsumed by corporate world grudges. Like most things in life, balance is essential.

 

Three.

iran-blizzard

The world’s deadliest known snowstorm began this February day in 1972, lasting a full week and killing around 4,000 people. The blizzard centered on the city of Ardakan in southern Iran, the region of Shiraz, cultural capital of Iran and known for the eponymous grape. Storyteller Isak Dineson (Baroness Karen Blixen-Finecke, 1885-1962) linked that grape to urology in her short story, The Dreamers: “What is man when you come to think about him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.” Blixen created coherent and compelling stories at a moment’s notice, and told her own life story in the 1934 book Out of Africa, that became a film in 1985 with Meryl Streep and Robert Redford. The complete passage in The Dreamers is particularly intriguing and relevant to urologists.

“ ‘Oh, Lincoln Forstner,’ said the noseless story-teller, ‘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? You may even ask which is the more intense craving and pleasure: to drink or to make water. But in the meantime, what has been done? A song has been composed, a kiss taken, a slanderer slain, a prophet begotten, a righteous judgement given, a joke made…’ ”  [Isak Dinesen. Seven Gothic Tales. The Dreamers. 1934, Random House. P. 275.]

Blixen’s choice of Lincoln for the first name of one of the three central characters in her imaginative story is curious, for although it is a well-known surname it is an uncommon given name.

karen_blixen_and_thomas_dinesen_1920s

[Karen Blixen and brother Thomas Dineson on her farm in Kenya, c. 1920s. Royal Danish Library.]

 

Four.
Imagination is the ability to form ideas, images, and sensations without direct sensory input. The practice of medicine, its instruction, and its innovation demand imagination. The imagination to think through the plausibility of things, is inseparable from critical thinking. Observation and reasoning, experience and experiment, are feats of imagination that challenge dogma with new ideas in search of the best truth possible. Such creative thinking is a necessary, but often forgotten piece of the essential skeptical analysis that good physicians and scientists practice and instill in students, residents, fellows, and colleagues.

A recent Lancet article referred to the early American physician Benjamin Rush (1746-1813), who called imagination “… the pioneer of all other faculties.”

“When Rush spoke of imagination, he wasn’t talking about dragons or unicorns, he called that mental faculty fancy, and fancy had no place in medicine. Rather, Rush was talking about how the doctor’s mind gathered observations and experiences, shifting and shaping them until new truths became clear. Memory was a component of this imagination, and understanding resulted from it.” [S. Altschuler. The medical imagination. The Lancet. 388:2230, 2016.]

I’d challenge the claim that no hard line exists between those dragons or unicorns and the new ideas, hypotheses, and truths we hope to discover. Fanciful fiction, visual art, and music enrich mental milieus and provide metaphors, symmetries, dissonances, harmonies, and analogies that make clinical work and science sharper, more multidimensional, and of greater relevance than they would be without the “fancy.” E.O. Wilson infers this in his conclusion to Consilience, a book named for and about the unity of knowledge.

“The search for consilience might seem at first to imprison creativity. The opposite is true. A united system of knowledge is the surest means of identifying the still unexplored domains of reality. It provides a clear map of what is known, and frames the most productive questions for further inquiry. Historians of science often observe that asking the right question is more important than producing the right answer. The right answer to a trivial question is also trivial, but the right question, even when insoluble in exact form, is a guide to major discovery. And so it will ever be in the future excursions of science and imaginative flights of the arts.” [EO Wilson. Consilience. Alfred A. Knopf. New York.]

Creativity can also spring from irrational thought as a song in the new film La La Land suggests. Audition (The fools who dream) sung by Emma Stone: “A bit of madness is key, to give us new colors to see. Who knows where it will lead us and that’s why they need us.” Human exploration of reality requires consilience of all the tools we can muster, including scientific knowledge, historical facts, stories, and imaginative fancy.

 

Five.

puppet
When you read a story or experience visual art you may discover something new to which your brain can connect and that will illuminate other stuff in your brain at that moment or later on in reflections, dreams, or sudden denouements. Those connections provoke imagination, test reality, and elicit wisdom that affects your world view and your work. Insight and inspiration from art provide limitless opportunities in the practice, teaching, or investigation of medical care. The story of British pediatrician Harry Angelman (1915-1966) offers a minute and excellent example of illuminating connection.

“It was purely by chance that nearly thirty years ago (e.g., circa 1964) three handicapped children were admitted at various times to my children’s ward in England. They had a variety of disabilities and although at first sight they seemed to be suffering from different conditions I felt that there was a common cause for their illness. The diagnosis was purely a clinical one because in spite of technical investigations which today are more refined I was unable to establish scientific proof that the three children all had the same handicap. In view of this I hesitated to write about them in the medical journals. However, when on holiday in Italy I happened to see an oil painting in the Castelvecchio Museum in Verona called . . . a Boy with a Puppet. The boy’s laughing face and the fact that my patients exhibited jerky movements gave me the idea of writing an article about the three children with a title of Puppet Children. It was not a name that pleased all parents but it served as a means of combining the three little patients into a single group. Later the name was changed to Angelman syndrome. This article was published in 1965 and after some initial interest lay almost forgotten until the early eighties.” [Quotation from Charles Williams. Harry Angelman and the History of AS. Stay informed. USA: Angelman Syndrome Foundation. 2011.]

Giovanni Francesco Caroto (1480-1555), the Renaissance painter in Verona, created the Portrait of a Child with a Drawing and the circumstances of the subject will probably never come to light. It may well be a coincidence that the picture resembled the patients that provoked Angelman’s curiosity.

chromosomes

[Chromosome 15]

chr-15
Deletion or inactivation of genes on maternal chromosome 15 with silencing of the corresponding normal paternal chromosome is responsible for AS. Similar genomic imprinting, but with deletion or inactivation of paternal genes and silencing on the maternal side happens in Prader-Willi syndrome, that shows up more often in our pediatric urology clinics. These two conditions along with Beckwith-Wiedemann and Silver-Russell syndromes were early reported instances of human imprinting disorders. An excellent update on these conditions appeared last month in Science. [J. Cousin-Frankel. Fateful Imprints. Science. 355:122-125, 2017]

 

Six.
New residents. We just matched our new cohort of PGY1s, a stage of medical education once called internship, that starts each July to initiate the transition of medical students into specialists. The medical student is the last universal common ancestor in the evolution of a medical specialist. About 150 areas of focused practice (per American Board of Medical Specialties) are available to freshly minted MDs and those last universal common ancestors in medicine evolve into the new species of their chosen specialties during their residencies.

This educational experience is a primary reason we exist as a Department of Urology. The UMMS was formed to produce the next generation of physicians for the State of Michigan in 1850 when this mission required 2 years of medical school lectures to achieve the MD necessary to practice medicine. The medical school then needed only 5 faculty and 2 departments (Medicine as well as Surgery and Anatomy) to provide that education. Today’s world of specialty medicine requires 4 years of medical school (with lectures, laboratory work, and clinical experience) as well as graduate medical education in one of 100 areas of specialty training offered here in Ann Arbor. Our medical school faculty numbers 2500 in 30 departments. We educate, at any moment, about twice as many residents in specialties as medical students – and the period of residency training may be more than twice as long as medical school itself.

New members of the UM Urology family are: Juan Andino with BS, MBA, and MD degrees from UM; Chris Tam with BS from UC San Diego and MD from the University of Iowa; Robert Wang with BA and MD degrees from Washington University in St. Louis; and Colton Walker with BS from Stanford and MD from Louisiana State University in New Orleans. Who knows where they will lead us?

 

Seven.
Darwin & Lincoln’s birth, on the same day in the same year, was the wonderful coincidence of February 12, 1809. Two more different circumstances for those neonates would be difficult to imagine although both families had roots in England. Both men had big imaginations that changed the world in positive ways that endure today. Darwin arrived in the center of the civilized world, Shrewsbury England, to a prosperous family. His grandfather, Dr. Erasmus Darwin, was one of the great thinkers of his time and his father Dr. Robert Darwin was a successful physician. The house where Charles Darwin was born was distinguished enough to have a name, The Mount. Abraham Lincoln was born in a small primitive cabin, now long gone, on the Sinking Spring farm on the western periphery of a nation barely 33 years in existence. The nearest town, Hodgenville, didn’t even get its name until 1826, long after the Lincoln family, short on money and education, had moved on.

400px-charles_darwin_photograph_by_herbert_rose_barraud_1881

[Above: Photo by Herbert Barraud, last known picture of Darwin. 1882. Huntington Library. Below: Last known high-quality Lincoln photo, March 6, 1865. Library of Congress.]

lincoln-warren-1865-03-06-jpeg

Darwin’s idea, The Origin of Species, contained the belief that species couldn’t breed with different species. The classic example of reproductive isolation that many of us recall from childhood was the mule, the result of a donkey and horse breaking the species barrier recreationally, but the resulting progeny was sterile and incapable of creating a further bloodline. That belief in a barrier to interbreeding, or hybridization as biologists term the process, has fallen away in the new era of genomic information. The Neanderthal and Denisovan genes in the Homo sapiens genome is a rather intimate example of species interbreeding. It turns out that hybridization has played an important role in evolution throughout most kingdoms of life.  The mule is joined by the liger (lion/tiger), Hawaiian duck (Mallard/Laysan duck), red wolf (coyote/gray wolf), and pizzly (polar/brown bear). Domestic dog and wolf interbreeding has given wolves a variant immune protein gene, β-defensin, that conveys a distinctive black pelt and improved canine distemper resistance to wolf/dog hybrids and their descendants. [Elizabeth Pennisi. Shaking up the tree of life. Science: 354:817-821, 2016.] In a practical sense for our work in healthcare, bacterial swapping of DNA presents great challenges. Darwin recognized a mighty force – nearly as mysterious and pervasive as gravity – that crops up way beyond biology. Even in social ebbs and flows of life, Darwinian forces are at play, for surely they have made markets, politics, and academia increasingly creative.

 

Eight.
LUCA. Central to the multiple facets of our interests and knowledge as clinicians, surgeons, and urologists, we are ultimately biologists. In that spirit, the mystery of how life began on Earth is an irresistible intellectual puzzle and if you align to the Darwinian line of the speculation the concept of a very simple common ancestor holds traction.

Such a single cell, bacterial-like organism would have begat the three great domains of life: archaea, bacteria, and later the eukaryotes. Of the 6 million protein-coding genes in DNA data banks, William Martin et al at Heinrich Heine University in Dusseldorf speculated that 355 were present in that most primitive of ancestors, called the Last Universal Common Ancestor (LUCA). These probably originated around volcanic sea vents that supplied just the right conditions. Whether or not LUCA came from sea vents, warm ponds, or other environments should become clearer as biologists dig deeper into our roots. LUCA might have looked like any of the archaea and bacteria we recognize today with stiff walled rods or cocci. More complex shapes required the flexible cell walls that came later with eukaryotes. LUCA probably existed as an anaerobe in a vent-like hydrothermal geochemical setting and was based upon 355 genes according to a paper from the Institute of Molecular Evolution at Heinrich Heine University in Düsseldorf.

luca

[Figure from MC Weiss, FL Sousa, N Mrnjavac et al. The physiology and habitat of the last universal common ancestor. Nature Microbiology. 1, Article number 16116, 2016.]

Much has happened since LUCA. Given the Darwinian trials of variation by error in the face of minor and gross environmental challenges over millions of millennia, new species developed in fits and starts. The Cambrian explosion of new creatures was one of many responses of speciation to planetary change. We humans seem to be at the far opposite end of the phylogenic spectrum from LUCA. Our complexity is not just a matter of our biology and our cerebral skills, but no less a matter of the social nuances that elaborate the human condition.

 

Nine.
A Fortunate Man. The classic study of an English general practitioner in the 1960s, alluded to on these pages last year sharpened my perspective as a physician. [John Berger, A Fortunate Man, Random House, NY 1967.] The ancient perspective of healthcare, documented since medical recipes in ancient early Egyptian papyri and Hippocratic writings, was a matter of dualities: one patient-one physician, one problem-one solution, and one teacher-one student. This changed in the past century due to medical specialties and technology that have introduced unmeasurable complexity. Patient care and medical education are no longer two-body problems, but are now part of a multidimensional healthcare matrix.

Even that multidimensional professional matrix is dwarfed by the complexity of patients with their own multidimensional physical, mental, familial, social, economic, political, and environmental comorbidities. You might lump all these comorbidities together and simply call them “the human condition” that Berger probed in A Fortunate Man, hinting that we really have little sense of what our patients are all about. However, as we practice our art, we become better at understanding the holograms of the patients as they present themselves in our clinics even in the short time frames at hand and the insistence of electronic health records and economics that force us to default to two-body problems (augmented with a few clever comorbidities that can permit a more realistic billing code).

Berger died last month (January 2) at 90 in the Parisian suburb where he lived. I didn’t know much about him since I read his book just last year (and I wish I could remember who told me to read it). Berger (pronounced BER-jer,) was known as a “provocative art critic” in the obituary by Randy Kennedy that included this example:

“He was a champion of realism during the rise of Abstract Expressionism, and he took on giants like Jackson Pollock, whom he criticized as a talented failure for being unable to ‘see or think beyond the decadence of the culture to which he belongs.’” [Kennedy. New York Times Tuesday January 3, 2017.]

The obituary ran for three columns and mentioned a number of Berger’s books, but not A Fortunate Man.

 

Ten.
That other birthday celebrant of February 12, 1819, would also have been 198 years old this month. Human biology at its best wouldn’t have given Lincoln that chance, but it was political extremism that cut him down short of his potential fourscore and ten years. While Darwin’s ancestors provided more than a hint of greatness for their descendent, Lincoln’s ancestry offered no such clue, but his insatiable drive for education and personal distinction contrasted remarkably with the rest of his family. His improbable success in law and politics leveraged his even more unlikely ascent to the presidency of the United States. No one could have predicted that his ultimate comorbidity would have been an actor with a Philadelphia Derringer at Ford’s Theater on April 14, 1865.

currier-ives

wilkes_booths_deringer

rimfire-cartridge

[Top: Currier & Ives print of assassination April 14, 1865. Middle: The actual Derringer. Bottom: 0.41-caliber Rimfire cartridge.]

Lincoln’s assassin jumped to the stage and escaped on a horse waiting near the backstage door. The following day he stopped near Beantown, Maryland (now Waldorf) seeking treatment at the home of Dr. Samuel Mudd, an acquaintance, for a broken left fibula. Mudd cut off Booth’s boot, splinted the leg, provided a shoe, and arranged for a local carpenter to make a pair of crutches. After catching some sleep at the doctor’s house Booth travelled on to Virginia where he was caught and killed on April 26. Mudd was arrested, charged with conspiracy, and imprisoned at Fort Jefferson in the Dry Tortugas. He tried to escape once, but became a good prisoner and was released after pardon by President Andrew Johnson on March 8, 1869. Mudd returned home to Maryland where he lived until January 10, 1883 dying of pneumonia at 49 years of age. Mudd’s grandson, Dr. Richard Mudd, unsuccessfully petitioned a number of presidents (Carter and Reagan) and also failed in other avenues to clear the family name of the stigma of aiding Booth. The family name remains Mudd.

600px-booth_escape_route-svg

[Booth escape route. Wikimedia Commons. Courtesy, National Park Service.]

Our world has changed enormously since Lincoln’s time. The American democracy is better, healthcare  is more effective, and the Earth even when viewed from far out in our solar system looks amazingly different (below); Edison’s electrical illumination, invented in 1880, has impacted both the visible planet and environment due to the fossil fuel consumption for those lights.

earth-earth-at-night-night-lights-41949

A short book on Darwin and Lincoln, Angels and Ages by Adam Gopnik [Alfred A. Knopf, NY 2009] noted:

“What all the first modern artists, from Whitman to van Gogh, have believed is that, for whatever reason, and however it came to be, we are capable of witnessing and experiencing the world as more than the sum of our instincts and appetites. Our altruism is not simply our appetites compounded; our appetites are not simply our altruism exposed. ‘Reason … must furnish all the materials for our future support and defense,’ Lincoln said, and reason alone can point us to its limits. We can argue about anything, even about the nature and meaning of our mysticisms. [Kenneth] Clark called our liberal faith ‘heroic materialism’ and said it wouldn’t be enough. Human materialism or mystical materialism, is closer to it, and it remains the best we have. Intimations of the numinous may begin and end in us, but they are as real as descriptions of the natural; Sunday feelings are as real as Monday facts. On this point, Darwin and Lincoln, along with all the other poets of modern life, would have agreed. There is more to a man than the breath in his body, if only on the hat on his head and the hope in his heart.”

 

[Footnotes: Numinous = inspiriting spiritual or awe-inspiring emotions. Mystical = having spiritual meaning neither apparent to sense or obvious to intelligence.]

 

 

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

2017 is here

DAB What’s New January 6, 2017
Free, efficient, and equal government
3752 words

 

grand-rounds

One.

Let’s not leave 2016 without a few comments about December. At Grand Rounds Andrew Peterson, visiting professor from Duke, and Daniela Wittmann gave excellent presentations on urologic cancer survivorship. Andrew explained his remarkable survivorship/reconstructive fellowship in Durham and Daniela gave a 10-year review of our uniquely successful Brandon survivorship program.

galens

Medical students raise money for our Galens Society annual “Tag Days” in early December. Founded in 1914, Galens supports Mott Children’s Hospital and other organizations that benefit children in Washtenaw County. [Above: Paul Cederna of Plastic Surgery with MS1s Alex Tipaldi and Michael Klueh at the Taubman 2 Urology ACU.]

holiday-party

Our holiday party at Fox Hills entertained over 350 people with the expected surprise of Santa who had gifts for all the children (above). Pat Soter, her husband Jim, as well as Sandy and Bob Heskett, did the heavy lifting for this event and we thank them. Pat’s retirement leaves a major challenge filling her shoes. A faculty evening meeting (below) discussed residents progress, urology divisions, strategic planning, and John Stoffel’s stint as Acting Chair.

fac-mtg

Now that we are 6 days into 2017, Happy New Year from Michigan Medicine’s Department of Urology.

 

 

Two.

Liberty, once attained, is taken for granted. We grieve its loss, fight for it, but are not good at maintaining it. On this day in 1941 Franklin D. Roosevelt delivered his Four Freedoms State of the Union address. Pearl Harbor would happen 11 months later. FDR came to the presidency in turbulent times and became enormously popular, serving nearly 4 terms. Some people disparaged his social policies, yet few disputed his belief in essential freedoms: freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear.

washington

[Washington @ Delaware. Sully 1819. Boston Fine Arts Museum]

The State of the Union address is prescribed by Article II Section 3 of the U.S. Constitution. George Washington gave the first to Congress in New York City on January 8, 1790, 9 months into office. The new government had recently come to power after 11 of 13 states accepted the Constitution, but North Carolina waited to ratify, pending a Bill of Rights. Washington’s address, praised North Carolina’s acceptance two months earlier. (Rhode Island became the last of the 13 original colonies to ratify, later that year on May 29.) That first State of the Union address at 1089 words (page 1 below) is shorter than any of its successors.

Washington set the tone in the opening sentences.

“Fellow Citizens of the Senate, and House of Representatives. I embrace with great satisfaction the opportunity, which now presents itself, of congratulating you on the present favourable prospects of our public affairs. The recent accession of the important State of North Carolina to the Constitution of the United States (of which official information has been received) —the rising credit and respectability of our Country — the general and increasing good will towards the Government of the Union —and the concord, peace and plenty, with which we are blessed, are circumstances, auspicious, in an eminent degree to our national prosperity.”

The conclusion was optimistic.

“The welfare of our Country is the great object to which our cares and efforts ought to be directed. And I shall derive great satisfaction from a co-operation with you, in the pleasing though arduous task of ensuring to our fellow Citizens the blessings, which they have a right to expect, from a free, efficient and equal Government.”

We anticipate President Trump’s State of the Union will seek reconciliation of political polarities without yielding on core issues that decided the election. Healthcare will be heavily weighted to the legislative agenda of Paul Ryan and operational agenda of HHS head Tom Price (UM alumnus and orthopedic surgeon).

 

 

Three.

Year 1 UMMG. The ability to practice and innovate in healthcare drew many of us to medical careers, but these freedoms have become constricted. Specialization, systemic organizational impingements, economics, and regulation drive much of the constriction. Some laws restrict conversations between patient and physician, as if healthcare providers were agents of government rather than citizens with first amendment rights (after all, free speech was first in the Bill of Rights).

Consumer discontent over healthcare delivery dominates the news, but discontent from the perspective of practitioners is equally important; dissatisfaction within healthcare professions affects delivery, efficiency, education, innovation, and pipeline of future practitioners. We can’t solve all the national and regional healthcare problems from Ann Arbor, but we can influence their solution and serve as a best-of-class example.

The structure, governance, and policies of the UM Health System have re-assembled over the past year. Our new Michigan Medicine governance is certainly less monumental than Washington’s new union in 1790 and contains key differences. Whereas the US federal system depends on a three-way balance of power, Michigan Medicine intends an integration of authority. “Silos” that evolved over the past 150 years at UM – namely the Medical School (UMMS) and its faculty, clinical departments, hospital administrative structure, and research enterprise – while related and sharing many of the same people, often worked at cross purposes to defend budgets, becoming archipelagos of cost centers.

One year ago the UMMS and its Health System merged the positions of Dean and EVPMA (Marschall Runge). Three vice dean positions were created: Clinical Vice Dean/President of UM Health System (David Spahlinger), Academic Vice Dean (Carol Bradford), and Scientific Vice Dean (TBD). A new UM Hospital Board with healthcare expertise and regental participation will oversee the entire health system and medical school.

The re-organized health system has 3 main operating units: Hospital Group I (Main & CVC), Hospital Group II (Mott & Women’s), and the UM Medical Group (UMMG, formerly the Faculty Group Practice = FGP) that manages ambulatory practices as well as regional affiliations. In the 2007 FGP, UM ambulatory activities were divided into 90 Ambulatory Care Units (ACUs) intended to function under local control by the healthcare providers to maximize lean principles. The ACUs have grown to 150 and Timothy Johnson was just named UMMG Executive Director. Tim ran the Multidisciplinary Melanoma Program, served as Division Chief of Cutaneous Surgery and Oncology, led the very successful Mohs Ambulatory Care Unit director, served as training director of the ACGME fellowship in Micrographic Surgery and Dermatologic Oncology, and is the Lewis and Lillian Becker Professor of Dermatology.

tim-johnson

Tim’s skin cancer programs involve over 25 departments, divisions, service lines, and centers, and consistently earn superb ratings of patient satisfaction, employee engagement, and access. His programs  generate significant grant funding, publications, and clinical trials.
New governance structure, expanded facilities, and growing affiliations should allow Michigan Medicine to carry out its missions no matter how the greater US healthcare system evolves. The UM has a history of innovative morphology beginning in 1869 when a faculty house became a hospital – the first occasion for a university to own and operate a hospital. While this originally happened for the purpose of teaching, the mission evolved to become a conjoined one of education, research, and state-of-the-art clinical care.

 

 

Four.

Inclusion of a hospital within the Medical School, extended medical education from classrooms to bedsides, a first step in building the UM Health System. Clinical and investigational laboratories later brought science into medical education and created new opportunity for investigation and innovation. An ambulatory care building in 1953 and offsite clinics carried UM into outpatient healthcare that is now expanding into homes, workplaces, and other daily living spaces of patients. This fourth dimension of healthcare (1=classroom, 2=bedside/OR, 3=ambulatory clinic, and 4=patient life circumstances) complements health services research, as practiced in our Dow HSR division, opening doors between medical schools and schools of public health, pharmacy, natural resources, nursing, kinesiology, and sociology. Our North Campus Research Center (NCRC), acquired from Pfizer, facilitates integration of all healthcare dimensions. [Below: David Canter Executive Director NCRC & Marschall Runge]

runge-cantor

 

 

Five.

Polar arguments related to the future of health care are being fought simultaneously in political battlegrounds and marketplaces. One argument is that health care is “too expensive” and we often hear that “we’re giving too much away.” The other argument was summarized in The Lancet cover quotation just before the November election: “Whichever way the election goes, one issue is certain: the next president of the USA will inherit a country in which deep health and health-care inequalities exist along multiple lines, including income, race, and gender.” [Editorial. “America decides.” The Lancet. 2016; 388: 2209]

There is little doubt that healthcare as deployed today is expensive and many factors account for this, significantly the insurance-based paradigm, corporatization of healthcare, and regulatory costs. Fee-for-service (FFS) factors and waste in the system are also blameworthy. Although both can be mitigated, waste will never be eliminated in human processes and FFS always finds a place in any free society. When people complain that too much is being given away, they are likely referring to suspicion that “other people” benefit from services that they, as taxpayers, support. This sense of unfairness is deeply seated.

Just as deeply seated at the other pole of belief is outrage over the unfairness of healthcare disparities. The right to healthcare, many will argue, is essential to life, liberty, and the pursuit of happiness, ideas deeply ingrained in American civic belief. No less important is the fact that it is in the public interest for everyone to have a basic level of health care. It is in your interest that the person next to you, next to your family members, next to your colleagues, and next to your friends – whether on the street, in a store, at a restaurant, or on a plane – doesn’t have TB, measles, Ebola, or some other communicable disease. It is in all of our interests that air and water quality are good. It is in our interest that violently mentally ill people are not disrupting work places or driving on streets. It is in your interest that homeless people have health care. Every civilized country recognizes some national responsibility to provide health care, differing mainly in the mechanisms and extent of coverage.

Reconciliation of these polar beliefs is a political problem, an economic problem, and a public policy problem. No simple solution or model will likely satisfy all these problems and beliefs. The public wants availability, affordability, and quality, but finds it easier to provide any two of these attributes instead of all three.

 

 

Six.

Federally Qualified Health Centers (FQHCs) provide one avenue to health care. These community-based organizations target underserved health care needs. Established to provide comprehensive health service to the medically underserved and reduce emergency room care, the FQHC mission has shifted to enhance health care services for underserved, underinsured, and uninsured individuals in urban and rural communities. Care is provided to all patients, including migrant workers and non-US citizens, regardless of ability to pay, based on sliding-fee scales established by FQHC community boards. In return for serving all patients FQHCs receive government cash grants, cost-based reimbursement for Medicaid patients, and malpractice coverage under the Federal Trot Claims Act (FTCA) of 1946. The ACA set aside $11 billion dollars over 5 years to cover FQHC costs. FQHCs serve one in 13 people in this country.

Some of the approximately 2000 FQHCs in the US are small operations, while others like the Hamilton FQHC in Flint are substantial enterprises. Two federal agencies oversee FQHCs. One is the Bureau of Primary Health Care, under the Health Resources and Services Administration (HRSA). The other is the Centers for Medicare and Medicaid Services (CMS), also under the Department of Health and Human Services (HHS). The Health Center Consolidation Act of 1996 (commonly called Section 330) brought together funding mechanisms for community health facilities, such as migrant/seasonal farmworker health centers, healthcare for the homeless, and health centers for residents of public housing. Previously, each of these organizations was provided grants under other mechanisms.

The Bureau of Primary Health Care is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA helps fund, staff and support a national network of health clinics for people who otherwise would have little or no access to care.

The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (HHS) administering the Medicare program and partnering with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov.

 

 

Seven.

hamilton

The Hamilton Community Health Network (HCHN) began in 1982 as the Hamilton Family Health Center under St. Joseph’s Hospital (now Genesys Health System) in response to unmet healthcare needs in Flint, Michigan. Moving to the present site (now the administrative headquarters shown above) in 1988 it began receiving federal funds to provide healthcare for the growing homeless population. Becoming HCHN in 2001 the organization assumed financial and operational responsibility from Hurley Hospital for primary and preventive care at the hospital’s North Pointe facility, and the following year began operations at a combined medical-dental site in partnership with the Genesee County Health Department. Hamilton, now a part of a national network of primary care centers (Section 330E), provides comprehensive healthcare services for underserved urban, rural, and homeless populations in addition to operating a family medicine residency program under HSRA funding since 2014. Hamilton has 6 clinical sites: the Main Clinic, the Burton Clinic, the Dental North Clinic, the Clio Clinic, the Lapeer Clinic, and the North Pointe Clinic. The Main Clinic is a new $5 million facility of 31,000 square feet, funded by federal dollars, local grants, a capital campaign, and debt that has been totally paid off.

The pairing of urology and primary care practices is natural. The Hippocratic Oath 2000 years ago recognized the unique nature of urologic expertise and the need for specialists. Every human being will have urologic issues of one sort or another and there will never be enough urologists to “go around.” Working side-by-side with primary care providers, urologists can teach them, just as they can teach urologists, providing comprehensive health care where and when it is needed.

ham-board

[Above: Hamilton FQHC in Flint: Board of Directors. Below CMO Mike Giacalone Jr., CEO Clarence Pierce]

mike-clarence

The UM Urology Department began clinics at Hamilton in 2015 working with an excellent clinical team including a superb physician’s assistant Ben Busuito (below). Urology clinics are now staffed nearly every week by myself, John Wei, John Stoffel, Anne Pelletier Cameron, Ganesh Palapattu, Meidee Goh, Chad Ellimoottil, and Gary Faerber – who has been coming back periodically from Salt Lake City. Our faculty have never been assigned to Hamilton nor subsidized to travel to clinics; we simply created the arrangement and our urologists saw the need and the opportunity. My clinic at Hamilton is streamlined for patients and providers, so my time in Flint is also a learning experience to improve our UM ACUs.

ben-team

[Clinic team: Melanie Slackta, Alice Yanity, Ben Busuito, Michelle Durall, Michelle Williams]

 

 

Eight.

True facts. Legendary professor Don Coffey at Johns Hopkins often admonished trainees: “You have to understand the difference between facts and true facts,” advice that resonates with me in this new milieu of fake news on social media. Don taught the importance of critical thinking and insistence on truth. The truth matters in science, in politics, and in all human interactions.

American philosopher Harry Frankfort wrote an important book entitled indelicately, but appropriately, On Bullshit (Princeton University Press, 2005) and this demanded a sequel the following year, On Truth (Alfred A. Knopf, 2006). Both books are worth your attention. (friend at Emory gave me a copy of the former book). If you’ve read them once you should read them again. True facts seem to have diminished influence today and false news is on the rise. Expect change in 2017. Worldwide social media communication will drive much of it, but dig critically for truth and its impostors.

orson_welles_war_of_the_worlds_1938

[Oct. 31, 1938: Orson Wells telling reporters no one expected the broadcast would cause public panic. Acme News Photos. Wikipedia]
The infamous War of the Worlds radio play in 1938 is a cautionary tale. The HG Wells story was directed and narrated by Orson Wells (no relation), but listeners who tuned in after the introduction misinterpreted the play as an actual alien invasion. Modern social media technology has increased the ease of dissemination of erroneous stories or deliberate manipulative propaganda. A single false story or conspiracy theory can spread around the planet in minutes to reach a sizable part of our 8 billion gullible global citizens. With print media and professional journalism on the decline, the world is dangerously vulnerable to manipulation by a random or purposeful catalyst.

The best defense against tomorrow’s War of the Worlds will be based on two foundering, elements of civilization. One is education – teaching critical thinking skills. That education needs to begin in grade school and sharpened later on the educational ladder in math, physics, physiology, and pharmacology just as well as in English, art history, or architecture. Broad critical thinking needs to continue in professional schools, graduate medical education, and beyond in our jobs and communities. The other element is a multiplicity of robust, trusted, and critical media sources providing timely scrutiny and analysis – and these are the fourth and fifth estates.

 

 

Nine.

Medieval social power structure can be conceptualized to three estates of the realm, namely the clergy, the nobility, and the commoners. The American colonies that united under George Washington disrupted that traditional model to create representational democracy and it is no mere coincidence that one of its early builders was a printer, Ben Franklin. Imperfect as it was and is, representational democracy surpasses anything else that has been attempted for civilized governance, but it demands an educated populace and continuous vigilance by the press, known as the fourth estate.

The immediacy of social media led to the concept of a fifth estate, consisting of web-based technologies. Curiously, that was the name of a countercultural underground newspaper, first published in 1965 in Detroit. The first issue included a review of a Bob Dylan concert, a “borrowed” Jules Feiffer cartoon, and announcement of a march in Washington. The periodical remains active and is believed to be the longest-running anarchist publication in English. The Fifth Estate archives are held here at the University of Michigan in the Labadie Collection at the Harlan Hatcher Library. [Below: First page first edition Nov 19-Dec 2, 1965. Courtesy UM Labadie Collection & Julie Herrada]

fifth

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What’s New/Matula Thoughts, this particular small-scale electronic posting, was intended as monthly essay for colleagues and friends. It has worked its way around the global village although we can’t track the What’s New email version that gets forwarded beyond its initial recipients, we can track the MatulaThoughts website version through WordPress analytics.

stats-mid-dec

[Above: MatulaThoughts analytics in mid-December]

Most web postings of this sort feature short blurbs linked to aggregated articles that may, or may not, contain verifiable reporting or critical analysis. MatulaThoughts differs in that its 10 items contain some streams of continuity, random observations, and specific references usually to scientific literature. Striving to keep this under 4000 words, we view this as a monthly essay for Michigan Urology family and friends, recognizing that while many find time for only a cursory scan, others pick out one or more items to read more carefully. Some readers around the globe, however, read this better than I write it, and communicate back related observations, different opinions, or find mistakes I’ve made. My thanks, especially, to those critical analysts.

 

 

Ten.

The Fifth Estate, just as the fourth, was heralded as a boon to free speech, human liberty, and democracy. Outrageous claims or gross propaganda, however, bring a perverse twist to social media, abetted by public tolerance and even an appetite for fake news. The boundary between fake news (mainly enjoyed as entertainment) and true factual news is indistinct and the difference doesn’t seem to matter to many people. This imperils democracy for it cannot be doubted that truth matters in a free and civilized society. Social media can provoke a presumably rational person to enter a church and open fire on parishioners, to take weapons to “investigate” restaurants in distant cities, to target-shoot highway drivers, or “execute” policemen in their cars. The truth matters to all of us. Its distortion undermines civilization.

Truth matters in science and is absolute in the health professions. Deception in the reporting of a blood test, cut-and-pasted notes, conversations with colleagues or patients, or manipulated scientific results may sneak by in the workplace or in the literature for periods of time, but eventually get discovered and demand public scorn and long-standing distrust. One rascal, even among thousands of “honest brokers” diminishes the public trust. Trust matters in engineering, construction, food safety, nuclear power plants, the transportation industry, water standards, air quality, and so on. It matters too in journalism, law, politics, and life in a cosmopolitan world. Purposeful exploitation of truth, whether self-serving lie, propaganda, or mischief should be called out. A related deception is that of careless or deliberate plagiarism, when another person’s distinct intellectual property such as sentences, images, etc. are claimed as one’s own.

How then can we distinguish these threats to free speech from fiction? To me, fiction is the art of creating a story that entertains and may give insight to our lives. The proper purposes of fiction (that is, the purposes that civilized and educated people should accept) are distinct from propaganda, deception, and plagiarism.

Freedom of speech carries with it the responsibility to be critical and intolerant of gross distortions. Preservation of the freedoms we claim as humans (namely, life, liberty, and the pursuit of happiness) demands an attention that in this country we elevated to a cabinet-level status under Dwight Eisenhower in 1953. This was the Department of Health, Education, and Welfare (HEW) with the motto, “Hope is the anchor of life.” In 1979 the Department of Education was split out and HEW became the Department of Health and Human Services (HHS). These organizations have spent much taxpayer money and have done great good, but are complex and imperfect. These have been, I believe, the only cabinet-level departments created by presidential reorganization. The ability of the president to create or reorganize bureaucracies, as long as neither house of Congress passed a legislative veto, was removed after 1962. Fifteen executive cabinet-level departments currently exist.

hew-seal

[Above HEW seal; below HHS seal]

hhs-seal

Although seemingly arcane, these matters demand our attention for a free, efficient, and equal government.

 

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