Rules, boundaries, and stories

DAB What’s New June 1, 2018

Rules, boundaries, & stories

3722 words

 

One.

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

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

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

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

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

 

Two.

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

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

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

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

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

 

Five.

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

 

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

But now back to 2018.

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

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

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

 

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

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

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

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

 

Ten.

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

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

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

 

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

Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

Each May brings a sweet spot to Ann Arbor’s calendar with mild temperatures, bright colors, chirping birds, and happy graduations. Foliage on the UM Medical Center ‘Hill” is a welcome sign of May and a favorite sight, seen above from last year, is a weeping ornamental cherry with spectacular magenta flowers. It sits outside the dean’s wing so enjoy it while you can, as that area is scheduled for demolition due to anticipated new construction. Magenta, a tertiary color and the complementary color of green, comes from mixing equal parts of blue and red on computer screens, midway between the two primary colors on a color wheel or with paint or crayons.

Maize & blue colors are prominent in graduations of the 19 schools and colleges of the University of Michigan this month. Michigan’s official azure blue is not quite the bolder darker “Go-Blue” color so well-known through our athletic programs. Azure blue is halfway between blue and cyan. Wikipedia describes azure blue as the color of the sky on a clear day, although looking out the window on a recent flight to Seattle it seemed that the sky can have many shades of blue.[Below: sky & mountains south of Great Falls, MT, with 737 engine.]

Medical School graduation is a grand occasion at Michigan and rightfully so being a milestone of medical education, the moment of awarding the M.D. The ceremony, at Hill Auditorium next week, reconnects attendees to the roots of our profession. Even if you don’t have a family member in the graduating class or are not a departmental chair sitting on the stage, the event is a lovely way to spend an hour or two on a springtime Friday, see the Michigan colors in the academic gowns and join a recitation of the Hippocratic Oath.

 

Two.
Resident and fellow graduation. Less widely recognized and less ceremonious. but equally important, is the career-defining milestone of a medical career, when residents and fellows celebrate completion of their training programs. Residency graduates are the capstone product of medical education, coming from the phase of graduate medical education (GME) that may exceed twice the time of medical school itself. Michigan has nearly two times as many residents and fellows in training as medical students at any moment and the education of all of them requires a large base of patients for clinical experience, especially at the higher levels of complexity. This is the key reason for the current expansion of Michigan Medicine; a referral base in the range of 4 million patients is necessary to support 2000 medical learners at Michigan Medicine, 28 of whom are in the Urology Department. Add to these nursing students, pharmacists, dentists, and others training and its clear how much depends upon a broad patient base.

[Urology graduation/Chief’s Dinner, 2015 – UM Art Museum.]

Numerous trainee graduations of clinical departments are scattered throughout Ann Arbor this month and next. The graduates then quickly immerse in their fields of choice to become independent practitioners. In time, they will be the experts of their generation and in this lengthy and complex educational process, “The Maize and Blue,” as the University of Michigan is informally called, is unsurpassed.

Urologists with Michigan roots comprise the Reed Nesbit Society, named after Michigan’s first urology section chief. Later this May the American Urological Association (AUA) holds its annual meeting where we will host our Nesbit reception that Sunday night in San Francisco. If you are reading this newsletter, whether Nesbit alumnus or friend, you are welcome to join us, so please contact our office for details. Our Department of Urology will have a vigorous presence at the AUA, with well over 100 presentations of various sorts and our faculty are active in most leadership forums and arenas.

 

Three.
The AUA origin story begins with Ramon Guiteras, a prominent New York surgeon who had interest and skills in genitourinary surgery. After work one day in 1900 he took his team to an East Side tavern, The Frei Robber, that featured homemade wine and limburger cheese. The pungent cheese kept other patrons strategically away from the clinical shoptalk. Amidst the fruitful conversation, the group named itself the New York Genitourinary Society and decided to meet periodically.

Genitourinary surgery was then a facet of general surgical practice and some surgeons like Guiteras were consolidating the special skills, knowledge, and new technology of its practice. Guiteras proposed a new word for the field, combining the Greek terms for urine (uro) and study (logy) and it seemed to catch on, even if semantically it doesn’t quite hit the mark of accuracy. Guiteras, no doubt, intended the word to capture the idea of the practice and study of the urinary (and genital tracts) as evidenced in his subsequent textbook of 1912.

The NY Genitourinary Society continued to meet at various locations. Two years later, assembling at the home of Guiteras, in February, the group renamed itself the American Urological Association, an intentional stretch, even though they all were New Yorkers. They held a “convention” in June, 1902 at Saratoga Springs. Membership expanded and the following year a second “annual convention” was held in New Orleans and a third in 1904 in Atlantic City, with 34 members in the convention photograph. In 1905 the group met in Portland, Oregon, reflecting the national growth.

By 1910, 320 active and 16 honorary members were listed and Hugh Cabot became president. His presidential address the following year, at the Chicago convention was: “Is Urology entitled to be regarded as a specialty?” Clearly, the Guiteras neologism had been accepted. Cabot’s Modern Urology in 1916 was the second authoritative urology text in the 20th century, and Young’s in 1926 would be the third.

Cabot’s rhetorical question reflected daily tension in the workplace between general surgeons and genitourinary specialists, still widely considered “clap doctors.” General surgeons resisted the loss of turf to a new cadre of highly skilled genitourinary surgeons like Cabot who were claiming the new clinical territory. Anesthesia, antisepsis, analgesia, and modern technology with electrical illumination, x-rays, cystoscopes, and precision instruments allowed the new breed of lithotomists to differentiate themselves. When Cabot came to Ann Arbor in 1920 he opened up the era of academic and modern clinical urology at Michigan.

 

Four.

Blues. Medical School and residency training graduations are highpoint in our circle of educational life. Above from the 2013 Medical School graduation you see current academic vice-dean Carol Bradford, former EVPMA Mike Johns in maize and blue, along with former dean Jim Woolliscroft.

While Michigan’s maize and blue is far flung around the world, another shade of blue, that of Levi Strauss, is truly ubiquitous, visible every day, nearly anywhere you find people on Planet Earth. I felt a little creepy when I captured the street scene below, but I wanted a picture of an anonymous person wearing these universal trousers. Such is the nature of human beings, that if a centralized government mandated everyone to wear a blue jeans uniform, people would find any excuse and no doubt risk punishment to avoid the uniformity. Ironically, despite their pervasive presence, blue jeans are an expression of individuality and freedom to be casual, comfortable, and at liberty to choose from a variety of jeans that seems nearly infinite in terms of hues, logos, fit, manufactured wear and tear (often with holes and rips), as well as actual states of well-earned damage. Blue jeans seem to be a mark of a free society.

Cotton’s utility is enormously important, but its production and manufacture tied to particular geographies came historically (and perhaps currently) at the cost of great human misery. Fustian, a heavy cloth woven from cotton, an odd word for most modern ears, is also used for pompous or overblown speech, deriving from cotton padding in clothing. The ancient city of Fustat, Egypt’s first capital under Moslem rule, was a center for cotton manufacturing, although it’s subsumed now by Cairo. Jeans, a trouser fabric, emerged from Genoa, Italy and Nimes, France. The term, jeans, may derive from Genoa. Denim, another cotton fabric, came from serge de Nimes. Dungaree was a thick cotton cloth allegedly named for a dockside village near Bombay called Dongri. Exported to England, dungri made good workman’s clothing that were often colored blue, as were jeans. The coloring dye, indigo, mostly came from Pakistan, although American plantations became another large source until indigo synthesis was developed in Germany in the 19th century.

Levi Strauss, an 18-year old German immigrant, with his mother and 2 sisters in 1847 joined 2 older brothers who had begun a dry goods business in New York City. Strauss’s name at birth (February 26, 1829) was Loeb Strauss, but he changed it to Levi in New York for ease of pronunciation. The family came from the Franconia region of the Kingdom of Bavaria, where Levi’s birthplace is now a museum.

[Strauss home, Buttenheim, Bavaria. Source: Wikipedia.]
After a stop in Louisville, KY to sell dry goods, Levi became an American citizen early in 1853 and moved to San Francisco in March of that year to head the family’s new shop in the epi-center of the Gold Rush. He lived with his sister Fanny and her family. The business, Levi Strauss Company, flourished, selling imported dry goods brought by ship to San Francisco and Fanny’s husband, David Stern, helped run the firm. Jacob Davis, a Reno tailor who regularly purchased bolts of cloth to make clothes, wrote Strauss in 1872 to ask for help patenting a heavy-duty trouser with copper rivets at stress points at pocket corners and base of the fly. After trials of different materials, including cotton duck (a linen canvas), they settled on denim (Genoa style “genes”) dyed blue. Davis and Strauss shared costs to develop the patent application and on May 20, 1873 US patent No. 139,121 was issued to Davis for “Improvement in Fastening Pocket-Openings.” These were originally called “riveted waist overalls.” Miners liked the durable trousers and “Levi’s” soon became popular with cowboys as well. The company grew robustly. Strauss never married and after he died in 1902, he left his estate and company, worth around $6 million dollars, to his 4 nephews.

 

Five.
The same year Strauss got off the boat in NYC, a Philadelphia physician, Samuel David Gross, published a book in 1851 that marked the start of a new era for the practice and study of genitourinary diseases. Gross, at Jefferson Medical College, was the most prominent of a new era of general surgeons, empowered by the new tool of anesthesia and skilled with broad capabilities across the human anatomic terrain, including areas that would devolve to surgical sub-specialists over the next century. As it happened, Gross was particularly interested in the genitourinary system, and proved his mastery of the emerging field with his textbook, A Practical Treatise on the Diseases, Injuries and Malformation of the Urinary Bladder, the Prostate Gland and the Urethra.

Having exemplified one paradigm shift, Gross missed the boat in failing to take note of antiseptic surgical technique, in spite of Lister’s convincing evidence published in 1867. The famous Gross Clinic painting by Eakins in 1875 celebrates Gross as a powerful surgeon, at first glance, but in fact calls him out as an “antisepsis denier” in contrast to the more rational Agnew Clinic, painted by Eakins 14 years later, coincidentally also in Philadelphia. Gross had no excuse, the conclusive antisepsis work by Lister in 1867 in The Lancet was well-recognized across the world. Gross obstinately led the American reaction against antisepsis saying in 1876:

“Little if any faith is placed by an enlightened or experienced surgeon
on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister.”

This story was nicely told here at our Chang Lecture on Art and Medicine in 2014 by Charlie Yeo of Jefferson Medical College. Both Gross and Agnew embraced the belief that general surgeons, true to their adjective, should cover the entire anatomic terrain when surgery was necessary. Evolving technology and specialized knowledge would make it impossible for that paradigm to persist. Ophthalmology was one of the earliest modern specialties to find its own turf. Genitourinary surgery remained encompassed within general surgery for a longer time, even though a number of leading authorities in general surgery embraced genitourinary skills by the turn of the 20th century. New technical skills and specialty knowledge was exceeding the ability of most general surgeons to keep up across the entire anatomical terrain and the growing number of subspecialty experts craved conversations and identification with each other.

 

Six.
Festschrifts are academic celebrations to honor people and careers, and two of these coincided, in Seattle, for great genitourinary surgeons. By chance, after my arrival for these, I ran into Nesbit alums Atreya Dash and George Schade who had just emerged from a conference at the Fred Hutchinson Institute (below, Nesbit 2004, 2013).

The next day, Virginia Mason Clinic (VMC) celebrated Dr. Robert Gibbons who, among many other things, pioneered the indwelling ureteral stent. After service in Korea, Bob was recruited to the clinic early in his career by Nesbit trainees Tate Mason, Jr. and Roy Correa (Nesbit 1949, 1965). The Michigan/VMC relationship grew deeper with Bob Gibbons’ mentorship of Jim Montie (below: Jim & Bob).

The day began with Grand Rounds at VMC, continuing through dinner on Mercer Island at the home of Kathy Kobashi (Section Head, Urology & Renal Transplantation) and Chris Porter (Uro-oncologist and Co-director of Clinical Research at VMC). Other VMC, UM, and personal connections emerged during the celebration. We saw Gary Kaplan, UMMS alumnus and the legendary VMC Chairman & CEO, who has returned many times to advise us in Ann Arbor (below: Gary, Chris, Kathy.)

John Ryan, VMC vascular surgeon, gave a wonderful talk on the use of the gracilis muscle in urology. We noticed him wearing a Nesbit Society tie from his dad, Dr. John Ryan (Nesbit, 1948). Steve Skoog, my friend since our days at Walter Reed and former chief of pediatric urology in Portland, OR (below) and John and Mary deKernion, friends and role models since my days at UCLA, were also on hand to honor Bob.

[Below: Jean and Mary DeKernion.]

Wally Gibbons, nephew of Bob and urologist in Wenatchee, Washington, came for the event. Wally’s group recently hired Ian McLaren (Nesbit 2017) who we hear is doing very well, as Nesbit alumni do. [Below: Wally Gibbons, Bob Gibbons, Bob’s daughter Jennifer Hayes, Jack McAninch, Kathleen Kobashi, Becky Schwaegler, Fred Govier, Jim Gasparich.]

The following day we celebrated Dr. Richard Grady, former UMMS student who became a pioneering pediatric urologist at Children’s Hospital under the mentorship of Mike Mitchell, innovator of the transformational single stage exstrophy repair. Rich carried this technique, along with general pediatric urology, fearlessly around the world, to underserved and sometimes dangerous locations. Rich’s event, held in the lovely University of Washington Research Buildings in downtown Seattle, featured friends of Rich from all over North America. It was a moving and richly educational day, highlighting Rich’s skill as a surgeon, educator, and connector of people. His kindness, optimism, and social responsibility were extraordinary, seemingly coalesced into his sunny smile, right to the end last year when brain cancer cruelly interrupted Rich’s life in spite of courageous therapeutic efforts.

Rich’s last appearance at the AUA national meeting was in New Orleans (below, 2015) where he had a podium appearance wearing a head device that he cheerfully explained was “birth control for brain cancer” utilizing tumor-treating fields (TTF) for an antimitotic effect that interferes with glioblastoma cell division and organelle assembly by delivering low intensity alternating electric fields (below). A randomized clinical trial for glioblastoma with TTF and maintenance temozolomide involving 695 patients in 83 centers found a median progression-free survival of 6.7 months in the TTF group vs. 4.0 months in those without the electricity, with corresponding improvement in median overall survival, a small but meaningful step. [Stupp et al. JAMA. 318:2306, 2017.]

 

Rich and his wife Laura moved to Southern California for another clinical trial (Chimeric Antigen Receptor T cell therapy) at City of Hope where he was the first patient to complete the treatment that, in fact, melted away his tumors, although the effect was not durable. Nonetheless, the astonishing result was an important increment of progress. Honoring Rich were Dave and Sue Bomalaski (Nesbit 1996) from Anchorage, where, Dave after retirement from the Air Force, practices with the Indian Health Service. Mike Mitchell from Milwaukee and Joe Borer from Boston are seen below on either side of Dave (below).

[Above: Grady Festschrift group photograph.]

 

Seven.
Hospice is an important part of healthcare. Most of us in the business of healthcare go to great lengths to avoid speaking of death. We want to be optimistic saviors of life and are uncomfortable speaking directly of its end. Having had little or no training in terminal life, we offer no more to our current trainees. Fortunately, our geriatric colleagues, palliative care experts, and hospice teams are uncommon exceptions to the rest of us. Rich’s last days were eased by hospice care as were those of a good friend, John Reed, former UM Law School Dean and neighbor of Dr. Chang, who passed away recently, having nearly reached 100 years of age with full capacities until the end of 2017.

Australian writer, Cory Taylor, published a noteworthy memoir two years ago, detailing her struggles with melanoma since 2005, noting among other issues that a metastasis obstructing her urinary tract “necessitated the insertion in 2011 of a plastic stent to keep my right kidney functioning.” She didn’t report further urinary tract issues, so presumably the stent was changed periodically and kept that area of her anatomy out of harm’s way.

Her book, Dying: a Memoir, confronts a phase of life that most people will experience, unless their death is violent or otherwise totally unexpected. Taylor’s writing is lucid, frank, and lacking in self-pity. I found the memoir unexpectedly comforting. As Taylor looked back on her life, toward the end, she objectively examined its many positive memories, and voiced particular regrets but didn’t let them drift into immobilizing grief. She explored the lure of personal euthanasia, finding comfort in obtaining the means for it, yet was held back by downsides she imagined: the horror of the person who would come upon her corpse and the idea that the taking of her own life would define her.

“It worries me, for instance, that my death certificate would read ‘suicide’ as a cause of death, with everything that the term implies these days: mental angst, hopelessness, weakness, the lingering whiff of criminality – a far cry from, say, the Japanese tradition of seppuku, or suicide for honour’s sake. The fact that cancer was actually my killer would be lost to posterity, as would the fact that I am not, by any fair measure, mad.”

 

Eight.

Indigo Carmine, a dye used by urologists, became unavailable sometime last year until we got it back on our shelves recently, as Bruce Angel (Urology Nursing Service Lead) informed me. A note he forwarded me from the OR pharmacies explained that the price has gone up from $3.00 per ampule to $123.45. Indigo Carmine (indigotindisulfonate sodium) solution was once used to in testing renal function, but now is mainly used to find ureteral orifices during cystoscopy. An intravenous injection of 5 ml (40 mg) appears in urine within 10 minutes.

Indigo is a natural dye extracted from certain plant leaves, most commonly the tropic genus Indigofera, that also has analgesic and anti-inflammatory properties. It is one of the less common natural colors and has an ancient record. Junius Bird (1907-1982), an American archeologist born in Rye, New York, and a possible inspiration for the fictional Indiana Jones, excavated a prehistoric settlement in Peru in the 1940’s that yielded the earliest evidence for human use of indigo dye.

 

Nine.

 

 

Sunshine on a cloudy day. When Smokey Robinson, in 1964, penned the lyric “I’ve got sunshine on a cloudy day and when it’s cold outside I’ve got the month of May,” he identified sunshine and May with the sweetest things in life. His inspiration, “my girl” of the song, was his wife Claudette and fellow Miracles band member. [Above: 1965 album; below Claudette Rogers Robinson, March 12, 2013 at star for the Miracles in Hollywood. Wikipedia.] I saw Smokey on a plane a few years back and he was still a magnetic presence, 50 years after that enduring song. May is a busy time for most people, but it’s an optimal time to restock and recharge the sweet memory bank with sights, sounds, and experiences of Spring.

Whether tomorrow brings sun or clouds, the greatest 2 minutes in sports, The Kentucky Derby, will bring its own form of sunshine for the crowd, the champion, and those who pick the trifecta. This will be the 144th race, although the trifecta only goes back to the 1970’s when the betting opportunity of picking first and second place finishers in order expanded to the first three. Smokey’s trifecta seems to have been Claudette, sunshine, and May.

 

 

Ten.
More shades of blue. Azure, as a color name traces back to the days of heraldry, deriving from the deep blue stone, lapis lazuli. A lighter blue, bleu celeste, more closely mimics the sky. Royal blue, darker than azure, dates back to a dress made for Queen Charlotte, consort of King George III. Driving down Washtenaw Avenue in May, east of the campus, you will see many blues splashed on “The Rock.” These colors come from real buckets of paint, rather than tidy computer color wheels and display the exhilaration of school kids anticipating the end of school and the freedom of summer or the intoxication of graduation. Some people driving by this object to the messiness, but most of us take pleasure in the exuberant freedom its colors reflect, with the schoolkids as stand-ins for the rest of us.

[Above: The Rock.]

[Above: refracted May sunlight on carpet. Below: color wheel from Wikipedia.]

Jill Macoska, Nesbit faculty alumna and currently the Alton J. Brann Endowed Distinguished Professor in Science and Mathematics and Cancer Biology at University of Massachusetts in Boston, was just back in Ann Arbor for the graduation of her daughter Nicole. Jill wrote last month to identify those tiny blue flowers mentioned here last month. “Good morning, David – Those tiny blue flowers are called ‘squill’; they and snowdrops are usually the first bulbs to poke their heads up out of the snow in spring!  Boston has been a good fit for the Macoska family. Nicole came back to UM for a double major in Political Science and Communications (Below: Class of 2018, high distinction, Phi Beta Kappa.).

Jill wondered how many new UM alumni children and grandchildren came from the Urology Family.

Department chairs no longer sign Medical School diplomas individually by hand. I miss the scheduled sessions when we took our turns signing upwards of 200 certificates (extras, because a few inevitably get messed up). It might be viewed as a waste of time, but for me it was a reflective ceremonial interlude. A sweet “hard-stop” in the busy cycle of academic medicine, the signing reminded me that we are here in our roles at Michigan for very consequential reasons. Below you see Dr. Valerie Opipari, Chair of Pediatrics, a few years back with the azure seal of the maize and blue up close.

 

Thanks for reading Matula Thoughts.

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

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.

January 5, 2018

DAB What’s New Jan 5, 2018

New year thoughts
3899 words

 

One.
Dripping icicles are picturesque winter images, although this week’s massive winter storm, Grayson, extending from Florida to Maine disrupted any nostalgic thoughts of snow and ice. The icicles photographed from my study window (above) echo the pendant spikes painted by Pieter Bruegel the Elder in Massacre of the Innocents circa 1565-67.

Bruegel’s icicles (above) look charming enough, until you view the grim larger work (below – original at Queens Gallery, British Royal Collection). One broken icicle is falling in response to men kicking in an adjacent door. The actual painting has a complex history of paint-overs transforming it from grisly slaughter of babies to the plundering of a village.

So, too, the larger work of today’s climate gives the icicle a chilling perspective, as it brings to mind the Greenland Glaciers, among other melting ice forms.

Although water’s origin on earth remains controversial, water is one of the key things astronomers seek when evaluating other planets that could initiate or sustain life. Water, so central to life, is a synonym in medicine for urine, amniotic fluid, ventricular fluid, lymphatic fluid, and other waters of our bodies. Frozen water in the form of sea ice and glaciers, more or less stable for the past 10,000 years, is melting at an extraordinary rate, threatening the delicate balance of planetary life.

A startling image from the U.S. Geological Survey (USGS) website shows how little the Earth’s water  compares to the volume of the earth itself. Paraphrasing from the USGS website:

The three blue spheres below represent relative volumes of Earth’s water in comparison to the size of the Earth. In comparison to the volume of the globe, the amount of planetary water is small; oceans account for only a thin veneer of water on the surface.

The largest blue sphere represents all of Earth’s water. Its diameter is 860 miles (the distance from Salt Lake City, Utah, to Topeka, Kansas) and has a volume of about 332,500,000 cubic miles (1,386,000,000 cubic kilometers). This includes all of the water in the oceans, ice caps, lakes, rivers, groundwater, atmospheric water, and even the water in living creatures.
The blue sphere over Kentucky represents the world’s liquid fresh water (groundwater, lakes, swamp water, and rivers). The volume comes to about 2,551,100 mi3 (10,633,450 km3), of which 99 percent is groundwater, much of which is not easily accessible. The diameter of this sphere is about 169.5 miles (272.8 kilometers).
The tiny bubble over Atlanta, Georgia represents fresh water in all the lakes and rivers on the planet. Most water that life on earth needs every day comes from these surface-water sources. The volume of this sphere is about 22,339 mi3 (93,113 km3). The diameter of this sphere is about 34.9 miles (56.2 kilometers). By comparison, Lake Michigan looks way bigger than this sphere, but you have to imagine the bubble is almost 35 miles high—whereas the average depth of Lake Michigan is less than 300 feet (91 meters). [With permission, Woods Hole Oceanographic Institute. Credit: Howard Perlman USGS, globe illustration Jack Cook, Copyright Adam Nieman.]

 

Two.

Dividing human moments into calendar years, we “start fresh” each new year with renewed opportunities to explore the world intellectually and geographically. The globe of the Earth is a tool and metaphor for human exploration as well as a visual remonstration to the “Flat Earth Society.” The globes shown above are displayed in a hallway in the Harlan Hatcher Library. If you work here at the University of Michigan or even if you don’t, but happen to be in Ann Arbor and want to explore the campus, “check it out,” when you have time.

Interrogation of the moment has been a uniquely biologic phenomenon. A rock is not aware of its environment even though it is affected by it. The rock cannot consider the things around it nor empathize with whatever it may roll down upon. Our human predecessors well before Aristotle thought about matters like this (they called them metaphysical) and passed these thoughts to their successors. When language and technology permitted, these metaphysical considerations were made somewhat durable in writing.

Biology shows that humans are not unique in this capacity of interrogation, even microorganisms react and respond to their microenvironments and communicate among themselves. All biologic creatures interrogate their moments, but our species has learned to do this very well and pass along observations for future generations to consider. We do this unwittingly by epigenetic management of our DNA and purposefully through our ideas, our culture, our objects, our written language, and our sports, as seen below in interrogation of the moment by Michigan quarterback John O’Korn during Ohio State game. [From Sincock Suite. November 25, 2017. Sony 24-240 FE]

Standing at the threshold of coexistence with systems built around artificial intelligence, we are now affected by their ability to interrogate us and to increasing degrees we are transferring many decision-making powers of our human agency to these systems.

 

Three.
Imagined Expectations. It may seem premature in this calendar year to mention Abraham Lincoln. Most any month but January provides a good excuse to think about Lincoln. His birthday was in February, 1819 and next month it will be the 199th anniversary. He died in April, 1865. His most famous speech, The Gettysburg Address, was in November, 1863. What brings him to my mind just now, however, is the starting sentence of that speech on November 19: “Fourscore and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.”

Lincoln’s remarkable use of the phrase “fourscore and seven” converted a mundane metric of 87 into a poetic measure of time. He was referring to the age of our nation, but that measure of time also equates to one very fortunate human life span, although for Lincoln’s time, in the antebellum South of the U.S., the average life expectation for a white male was 38.3 and 40.5 for a white female. I couldn’t find equivalent data for other men and women of color until 1900 when it was 32.5 for males and 35 for women. All such data is a suspect approximation for reality, and means little to the particular story of any individual man or woman.

My point here, admittedly a bit strained, is that our limited personal solar cycles provide a single human the opportunity to interrogate one’s times and world, so as to navigate it well and possibly to improve it for successors. Borrowing from Lincoln, three score and ten is a more typical fortunate expectation for most of us, given the personal good luck of health, security, and opportunity that communities and governments should provide. Four score and seven is a very optimistic expectation, and for that the luck and security of health is essential.

An individual human’s expiration date hinges on genetics, luck, opportunity, choices, and the general randomness of events. For me, as a youngster growing up in the rhetoric of the Korean War, McCarthyism politics, nuclear war anxiety, air-raid drills at school, and the personal insecurity of one’s own potential and relevance, the mere idea of surviving into the 21st century seemed fanciful. Yet here we are in 2018.

 

Four.

Dee Fenner, the new chair of the OB GYN Department, is a perfect choice for Michigan Medicine (seen above with husband Charlie at autumn DEI reception). Dee is a world-renown gynecologist, a superb educator, and a first-rate administrator who has gained the respect of her colleagues at Michigan in her numerous administrative responsibilities. She also holds a joint appointment with Urology, along with 3 other members of her team. Since the days when Ed McGuire was Section Head of Urology, our departments have had a close relationship. I well remember my earliest days here when Ed and John DeLancey had a combined pelvic floor dysfunction clinic on Saturdays. Dee and I met shortly before she returned to Michigan. We were in Paris at a WHO Consensus Conference in 2001 and by coincidence found ourselves in a pen shop as the only Americans.

Words of praise are due for Tim Johnson, the outgoing chair of OB GYN and a friend of urology for the 24 years of his successive terms. Few figures in his field have generated equal respect for leadership in national and international OB GYN. His work in Ghana is legendary. Tim brought his department at Michigan into the 21st century with superb clinical divisions, excellent faculty, coveted educational programs, and worthy contributions to the knowledge of his field. Tim has been a stalwart force in the domain of women’s rights. His sense of the centrality of the essential deliverable of kind and excellent patient-centered care (if you permit me some repetitiveness) has made him a terrific colleague. His department consistently and superbly delivers its products (forgive the relevant pun).

Sad news on the recent passing of Rudi Ansbacher, emeritus professor of OB GYN and a remarkable colleague.

 

Five.
Matula Thoughts, recap. Throughout the millennia of human history clues to predict the future have been highly prized, especially so when a given future is related to health. Entrepreneurial “healers” utilized external cues from the heavens, weather, tea leaves, or playing cards to prognosticate outcomes, although the logic of using physical evidence from patients or their byproducts was evident to early practitioners. Like most other mammals, humans share the trait of personal interest in their urine, and are particularly attentive when it is abnormal during illness. Hippocratic writings documented uroscopy, as examination of urine came to be called 2500 years ago, and over the ensuing millennia the practice attained imaginative prognostications as healers examined the gross characteristics of urine in flasks called matulas to speculate on the course of an illness. The visual image of a “piss prophet” gazing at a matula served as a main symbol of physicians until only about 200 years ago when the stethoscope replaced the flask as medicine’s badge of office.

We began this electronic journal nearly 18 years ago with a respectful tip of the matula to the essayist Michel Eyquem de Montaigne who began his eclectic personal observations around 1572 at 39 years of age. That was a turbulent time, notable in Europe for the sieges of Sancerre and Haarlem, in South America for the fall of the last independent remnant of the Inca Empire, and in the heavens for the first observation of Supernova SN 1572, that Tycho Brahe gave as evidence that stars are changeable. Montaigne was likely unaware of most big events of that year, but he was certainly acquainted with physicians and matulas, given that his father purportedly died of urinary stone disease and Montaigne himself began to suffer from them in 1578.

What impulses compel us humans to foist our personal observations and thoughts on our fellows may someday be revealed through the matula’s diagnostic successors such as the MRI and other marvels of imagination, but there is no arguing that those impulses are strong and prevalent. This monthly newsletter started in Allen Lichter’s dean’s office in 2000 as a way to interact with those among our faculty willing to consider some thoughts from a colleague. Admittedly, I wrote this column called What’s New as much for myself as any potential readers, but it became a pleasant habit to send out the first Friday of each month. Becoming chair of the University of Michigan Urology Department in 2007 the monthly column transitioned to our faculty, residents, staff, alumni, and friends. What’s New has served us well, connecting us to many of our intended audience and beyond. Some recipients kindly forward What’s New to their friends, although the extent of that particular reach is mostly unknown except for occasional readers who have contacted or commented to me as a result.

 

Six.
We began a parallel version of What’s New in March, 2013, on a website labelled Matula Thoughts. This version allows us to archive the monthly columns, thereby minimizing duplication and providing the unexpected voyeuristic capability of showing the numbers and distribution of web-version readers. Likely only some of them read this carefully, while most probably glance or sprint through it. Nonetheless, the surprising numbers and distribution are evidence of the internet’s ability to connect the world. [Screenshot below – 2017 statistics page of Matula Thoughts.]

Matula Thoughts, had over 2,300 views last year, ranging from single viewers in 24 countries, 2 viewers in 6 countries, and 3 in 11 countries. Forty-one countries had 4-85 views and the US had 2364 views as of mid-December, the map showing stats for the readership in 11.5 months of 2017. It has been enjoyable to hear from, or run into, the occasional reader of the web version.

With a new chair of the Urology Department, presumably this calendar year, What’s New may be continued or another vehicle of departmental communication may be utilized, but in either case Matula Thoughts will remain in its online form (matulathoughts.org) as long as I’m able and a readership exists. These spaces will continue to be filled by matters that catch my attention and may interest some readers.

 

Seven.
Each year has a certain cadence, whether calendar, academic, or fiscal for each of the countless social and business organizations around the globe. The success of a particular person, novice or experienced citizen, in navigating the year is partly contingent on that person’s understanding of the rhythms of work and expectations of their relevant organizations.

In a clinical surgical department, the 24/7 expectations of stakeholders set the central cadence for our essential deliverable – kind and excellent patient care. The stakeholders are patients, families, trainees, staff, faculty, referring health care providers, colleagues in other departments, and the community. Around this we build our educational conferences, work schedules, training cycles, maintenance of professional certification, peer review cycles, promotional steps, reappointment sequences, and social events such as our Holiday Party that last month hosted 400 people and 115 children who had encounters and gifts from Santa. As our department has grown large this event seems to have become increasingly treasured and is the single occasion to aggregate the greater part of our complex team.

The cadence of the new chair search will capture our attention. In the case of Dee Fenner and the OB Gyn Department the process took around 6 months. Dee was the natural choice and had passed up a number of other prestigious offers from other institutions in order to remain at Michigan. At this point she is the only other chair here to have a joint appointment with our department.

 

Eight.
Breakthrough of the year. Science, the AAAS journal, began a feature called Molecule of the Year in 1989, following Time Magazine’s Man of the Year that had started in 1927. Wikipedia relates that Time’s cover was originally a response to its embarrassment earlier that year in failing to put Charles Lindbergh on the cover following his trans-Atlantic flight. As the Man of the Year expanded to including all persons, as well as groups (in 1960 it was U.S. Scientists), ideas, or objects, so too did the Molecule of the Year to become the Breakthrough of the Year.

Science named the observation of cosmic convergence, a violent merger of two neutron stars on 17 August as the scientific breakthrough of 2017. Runners-up included cryo-electron microscopy observations on organic molecular function, thermoluminescence dating of early human roots, pinpoint gene editing techniques, preprint sharing in life sciences, FDA approval for checkpoint inhibitors, discovery of a new living species of Hominidae (the Pongo tapanuliensis orangutan), recovery of 2.7 million-year-old ice cores that contain ancient atmosphere (with CO2 levels under 300 ppm), and successful gene therapy for spinal muscular atrophy 1. Once again, biology dominated the main scientific achievements of the year.

 

Nine.

Disclaimer. Because of a few skunks in academic medicine, speakers at nearly every medical presentation around the world declare absence, or occasionally presence, of “conflict of interests.” Mostly these are silly declarations, and effective skunks either lie or mislead audiences with their declarations. It is easy to mislead others, because all social transactions, especially those in health care and in academia, are built on trust.

The necessary velocity and fluidity in science and medicine preclude extensive authentication and verification in real time. For example, when a colleague tells you that a serum creatinine is 0.8, you accept that as fact. Mistakes may happen in our workplaces, but they should sharpen our attention to truth and not let false facts become a way of life. Once, however, deliberate lies or plagiarism are revealed trust should never easily be restored. The cutting and pasting that has become so easy, indeed almost necessary, in the modern electronic medical record allows a very seamless slip from mistake to deceit, once a clinician starts to lose the sense of individuality of patients. When a physician loses that appreciation of the uniqueness of a patient, a history and physical for, let’s say a boy with undescended testicle, can be “generalizable.” Checking off a few boxes, or even cutting and pasting an entire H&P, is certainly more efficient than asking questions, observing the patient and family, and examining the child. This is akin to Paul Simon’s cynical song, The Myth of Fingerprints.

Another associated, yet perhaps minor, gripe I have with the EHR occurs in the operating room, when at the end of a procedure in the well-intended, but tedious “time out” I am asked to describe the blood loss. My claim of “minimal” is always rejected because the computer only allows a number. In many cases a tiny bit of red can be seen, but is it 0.5 ml or 5.0 ml? It is somewhere in that range, but unmeasurable, insignificant, and inconsequential. When I am asked to fabricate a number, my mind rebels and when I do come up with a number it feels more like a lie than a guess.

Anyway, with the start of a new calendar year I thought a disclaimer would be useful. Therefore, let me state that I seem to have no conflict of interest or conflict of commitment that would steer the comments in What’s New/Matula Thoughts to any drug, product, political party, or ideology outside of belief in liberal democracy (life, liberty, and the pursuit of happiness under representational government), public education, planetary conservation, social justice, and The University of Michigan. The thoughts herein, unless authorship is otherwise specified, represent mine alone. I don’t necessarily speak for our Department of Urology, Michigan Medicine, The University of Michigan, the State of Michigan, the United States, or the United Nations.

Hoping you are comfortable with these statements, I invite you to peruse, delete, comment upon, or forward What’s New (the email version) or Matula Thoughts (the web-site version) this new year of 2018. What’s New is a hint that we offer some news from our academic department and health center. Matula Thoughts is a term that hinges on an ancient symbol of the medical profession that was a transparent flask used to examine urine, one of the few clues to disease that ancient caregivers had available. The matula was replaced by Laennec’s invention of the stethoscope in 1816 in Paris, but both tools reinforce the threatened idea that physicians should look at and listen to their patients.

 

Ten.

 

The new year, 2018, began with Michigan’s appearance at the Outback Bowl in Florida four days ago and many red moustaches and haircuts in support of the Chad Tough Campaign for brain tumor research.

Alon Weizer is Acting Chair of our department for the next three months. This cycling of our associate chairs has been healthy for the department and for me. During this time I’ll be working on the UMMG Bylaws, helping re-activate our Michigan PAC, laying out plans for our centennial, and continuing some development efforts, and remaining active with the Hamilton Community Health Center and its board.

Some people have queried the administrative structure of our department. Our basic backbone is the Senior Clinical Management team, composed of our division heads, our residency program director, and our peer-review quality officer. The associate chairs have responsibilities that transcend divisions, for example the research portfolio, faculty affairs, operating room distribution, in-patient clinical operations, and ambulatory care management. Our ultimate responsibility, day-in and day-out, is the essential deliverable of kind and excellent patient care. Michigan Medicine, our other departments, the community, referring physicians, and the University of Michigan depend on our ability to do this very well. This essential deliverable is also our primary financial engine, as we defend and expand our markets. It should go without saying that these markets are clinical, educational, and academic markets.

We have been fortunate over the past 2 decades of Jim Montie’s and my terms in delivering our particular essential deliverable and in defending and expanding our markets. Few could find major deficits in those regards, as our external review by Mark Litwin, Ed Sabanegh, and Bradley Leibovich pointed out recently. However, the waters ahead will be turbulent and we will need a steady and resourceful hand who enjoys the support of our faculty.

This winter, a search committee convened by our deans is in the process of finding candidates for leadership for our department. Having experienced one disastrous change of leadership for Urology after Ed McGuire left us for Texas in 1992, we are aware of the risks of change, but our deans and the search committee at hand give us confidence in a good outcome. With superb division heads and associate chairs in place we have a very strong and deep bench. If there is a better external candidate on the planet, good for us, but it would be hard to beat our bench.

I don’t think I’ve left too many administrative problems for Alon, after all we have finished our main work of the cycles of reconciliation of FY 17 and planning for FY 19, on-boarding of new faculty, academic promotions, and residency recruitment. Alon will oversee the daily operations and occasional crises inherent to any business with several hundred employees, clinics at 16 sites, surgical teams at 9 locations, training of 28 residents and fellows, six separate investigative teams, etc.

Our new relationship with West Shore Urology in Muskegon has energized us and created a new reach to the west side of the state. The growing relationship with Mid-Michigan and with Metro Hospital also offer great opportunities. Our efforts with the Hamilton Community Health Network in Flint continue as well, and I’m especially grateful to members of our urology department and a few other UM departments who have participated in this important connection.

A busy year and a half lies ahead. In February we should hear the names of the new resident trainees to join our department. Our Departmental Retreat, April 14, will take stock of where we stand and where we are headed. The Teeter Symposium, May 4, will survey our work with bladder cancer. The Nesbit Alumni Reception at the AUA will be held on Sunday May 20 in San Francisco. During the Art Fair Season the Chang Lecture on Art and Medicine July 19 will inaugurate a new residency training season. The next day Hadley Wood of the Cleveland Clinic and Rosalia Misseri of Riley Children’s Hospital in Indianapolis will be the Duckett and Lapides Lecturers. The biennial Dow Health Services Research Symposium will take place September 13 and 14. Our own alumnus, Toby Chai of Yale University, will be Nesbit Alumni Visiting Professor September 20-22. The Montie Uro-Oncology Lecture is planned for early 2019, and later that year we will begin our Urology Centennial Celebrations to transition into the second century of urology at the University of Michigan, under improved new management, by then.

 

Thank you and Happy New Year from the Department of Urology of the University of Michigan.

 

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

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

Matula Thoughts July 7, 2017

DAB What’s New July 7, 2017

 

The Fourth, stories, & art

3789 words

This commentary from the University of Michigan Department of Urology is sent out on the first Friday of each month in two versions, the email What’s New publication and the web posting matulathoughts.org. Matula is an ancient term for diagnostic flasks once used to inspect urine.

Flag

One.              

July delivers a new cadre of interns/residents to hospitals around the country in the midst of divisive national controversy over healthcare. Momentary acronyms – ACA, MACRA, MIPS, AHCA, BCRA, etc. – rivet public attention, just as the next acronyms de jour will do a few years hence. Whatever paradigms and regulations spill out of Washington, the daily clinical work of healthcare, education of our next generation, and expansion of knowledge and technology will continue. New house officers leaping out of their starting gates this month may scarcely notice the regulatory nuances and social policy debates. I hardly noticed such matters at a similar time in my life in 1971, but today the impact of healthcare legislation and regulation seems increasingly important. These matters, furthermore, are deeply linked to the principles celebrated this past week, because foremost in America’s ongoing republican experiment is belief in human rights and self-determination and these are inextricable from health.

July 4th represents a pause of personal freedom and relaxation for most Americans. In addition to the general right of freedom, personal freedom requires a shared sense of social justice built on laws specific to given nations, societies and localities, such as speed limits in school zones, zoning rules, or sales taxes, yet aligned with universal human rights. Not all local laws meet the bar of social justice, examples are voting restrictions, sedition or blasphemy laws, childhood marriage, and eugenic sterilization. A book on the document that made the Fourth of July possible, Our Declaration written in 2014 by Danielle Allen, dissected The Declaration of Independence word-by-word, examined the milieu in which it was constructed, and distilled the underlying principles in its second paragraph (“We hold these truths to be self-evident …”) down to three “truths” after accounting for punctuation and syntax:

  • all people are equal in being endowed with the rights of life, liberty, and the pursuit of happiness, among others;
  • humans build governments to secure these rights and political legitimacy rests upon the consent of the governed;
  • when governments fail to protect these rights, people have a right to revolt. [Our Declaration. Liveright Publishing Corp. NY. 2014. 153.]

Fireworks2

[Fireworks, Barton Hills 2017]

 

Two.

The Declaration, read from a strict originalist or textualist perspective, or even interpreted from a common-sense viewpoint, places healthcare soundly within all three of those “inalienable rights.” Life speaks for itself, from birth through childhood and adulthood navigating the hazards of trauma, disease, and disability. Liberty is the matter of self-determination, a basic tenant of our nation and democracy. This is the freedom to make judgments, speak freely, pursue education, choose careers, or adopt life styles. Liberty requires personal independence and mobility, assets that logically depend upon health. The writers of The Declaration were specific in selecting pursuit of happiness as an inalienable right. The word, happiness, appears twice in the second paragraph of The Declaration. Happiness may have had a subtly different meaning 241 years ago, but it is likely that the Committee of Five charged by Congress to write The Declaration (Thomas Jefferson, John Adams, Ben Franklin, Roger Sherman, and Robert Livingston) did not intend a trivial or hedonistic sense. They recognized that people, individually and equally, shared the right to pursue happiness as they themselves determined that happiness and government was intended to be in service to its people: “…Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”

The Lancet last month included a relevant statement from a World Health Organization Working Group, speaking for health and human rights of women, children, and adolescents, but applying equally to all human beings and expressing the principles of The Declaration. The particular vulnerability of women, children, and adolescents throughout most of the world is a tragic reality built on countless stories, known and unknown. The Working Group comment extends beyond its particular portfolio because all human beings are vulnerable to catastrophes of climate, geology, famine, war, oppression, violence, economics, and biology.

“The powerful interplay between health and the human rights of women, children, and adolescents forms the cornerstone of the global development agenda. When their right to health is upheld, their access to all other human rights is enhanced. The corollary holds true. When their right to health is denied, the impacts inhibit their exercise of other human rights, undermining their potential …” [Halonen T, Jilani H, Gilmore K, Bustreo F. The Lancet. 389:2087-2089, 2017]

 

Three.

House officers and fellows explain their attraction to medical careers, at least in part, by belief in social justice and the opportunity to help people. Medical school debt, duty hours, documentation-compliance, RVUs, and personal well-being dampen those original attractors. Acrimonious debates on healthcare legislation center around views of healthcare as a right as opposed to healthcare as a commodity and personal responsibility. The words right and responsibility require deeper consideration, for example in a recent radio interview Tom DeLay, former U.S. Representative from Texas (1979-1983, 1985-2006) and House Majority Leader (2003-2005) stated he doesn’t believe that health is a right, but rather a responsibility. [Interview on NPR with Jeanine Herbst March 22, 2017.] His point that government has no “constitutional role in health insurance” is accurate from a textual Constitutional perspective, however to reduce the generality of healthcare to the particularity of health care insurance is neither logical nor helpful in the national debate. I use the DeLay quote only to introduce the consideration of healthcare as a right, not because of any claim to healthcare expertise or salutary wisdom regarding social justice he might offer.

Ian & Ted

[House officers Matt Lee & Ian McLaren choosing freedom over local rules.]

The truth in healthcare is close to home for most people. Health care involves each of us from antenatal days to final days of life. It is not productive to frame the national healthcare debate in the context of healthcare insurance, as insurance is only one method to fund a nation’s healthcare needs. Viewing the enormous panorama of national healthcare from only the insurance perspective makes no more sense than expecting the motor vehicle insurance sector to cover all motor vehicle costs including purchase, gasoline, cleaning, maintenance, safety inspections, collision repair, and damage from acts of nature, as well as highway safety, research and development, petrochemical sourcing, and traffic control.

The insurance industry, arguably, began at Lloyds Coffee House in 1686 of London as a source of shipping news and later marine insurance to mitigate catastrophic risks of sea commerce (above c. 1800 unknown cartoonist. Wikipedia). Insurance did not cover all expenses of sea trade, it covered true catastrophe, not operating costs, torn sails, or men overboard. The origin and evolution of American health insurance and the co-mingling of it with employment status is a story with many twists and turns, and federal involvement added further complexity. The result is an intertwined morass of funding streams and regulations, kinda looking like the Lloyd’s cartoon above. Rather than partisan ping pong, the solution to the national healthcare dilemma requires thoughtful bipartisan consideration of a framework to define rational public and private domains, responsibilities, and funding.

 

Four. 

Debate, essential to democracy, requires free speech and an open society that embraces education and cosmopolitanism. Conversations that challenge opinions, introduce ideas, and work toward consensus are fundamental to civic life as well as just and constructive public policies. This is how democracy works best, whether on national stages or in local workplaces.

Point counterpoint

We bring debate to Michigan Urology with point-counterpoint sessions at Grand Rounds when two residents square off with contrasting points of view to sway the rest of us. Our discussions are more prosaic than debates of health care as a right or commodity, because we are focused on learning urology. For example, Parth Shah recently offered the opinion that radical cystectomy should be performed by traditional open technique while Zach Koloff argued for the robotic platform (pictured above). They reinforced their positions with historical perspective and current data, deploying classic elements of argument. The impeccable characters of Zach and Parth represented ethos, their data supported logos of their claims, and considerations of pain, costs, complications, learning curves, and fiduciary responsibility bore pathos in the traditional rhetoric triad. The hospital conference room, newly refinished, was pretty much at capacity with about 45 in attendance including the usual 4-6 lurking at the back of the room with coffee and opportunity for stealthy egress.

 

Five.

The recurring biologic experiment of civilization evolved occasionally from the social networks animals depend upon to maintain each generation. A few eusocial species, if I may flip back to the writings of E.O. Wilson, create societies that successfully and become durable “megaspecies” in and of themselves. Wasp, bees, and ants are most notable, using chemicals or motions for communication. Specific signals trigger unified mass social actions such as directional movement, panic, or war. Ants, for example, manage their colonies with pheromones.

Fire_ants_01

[Above: marching fire ants, Stephen Ausmus http://www.ars.usda.gov/is/graphics/photos/dec04/k11622-1.htm]

The human advantage with civilizations is an ability to build and change them over centuries through communications transcending many generations and even millennia, allowing learning, creativity, and innovation. Individuals apply critical thinking, reexamine assumptions, experiment, analyze methodologically, and cooperate for durable change, passing information along to successive generations. Individuals naturally have individual points of view and debate allows cooperation and learning, leading to resolution, reconciliation, and centrism.  A strong center is essential for robust civilization, but just as ants and bees, humans are subject to mass manipulation by signals that, usually for us are money, ideology, propaganda, quackery, or charisma.

 

Six.

Conspiracy theories attract and entertain.  We are drawn to them, being hardwired to favor stories that fit our predispositions or play to our anxieties. Conspiracy ideas provide lazy mental short-circuits that displace critical thinking and rational re-examination of assumptions. Some conspiracies, of course, prove authentic, although my limited experience in the military and as an amateur student of history, is that major conspiracies are unlikely to remain long-concealed. Democracy is leaky due to First Amendment protections of free speech. Rare exceptions, such as campaigns that “loose lips sink ships” or the Manhattan Project, demonstrate that free society can maintain secrecy for critical intervals on rare occasions when the need is essential and widely understood. The rarity of these exceptions preserves their exceptionalism. When a regime tilts toward authoritarian rule and censorship becomes common, democracy slides away.

It is not wrong that news sources are polarized. The left side of the political spectrum reads left-sided sources while the right reads right-sided sources, and everyone blends opinions, facts, and stories to support their myths and to ascertain facts. The middle of the political spectrum is where democracy finds its balance, but sources of news and opinion that the center trusts are uncertain and conspiracy fears can spread like viruses.

400px-RoswellDailyRecordJuly8,1947

On this day in 1947 Major Jesse Marcel, intelligence officer of the 509th Bomber Group at Roswell Army Air Field inspected a debris field where an incident was claimed to have happened. [Above: Roswell Daily Record, July 8, 1947] Stories still emanate from that incident, blending facts and myths with no commonly-held authoritative version, but only colorful conspiracy theories. Those of us who grew up with the original X-Files series (1993-2002), centered around Roswell-type mysteries, are familiar with the haunting tune and the invitation to further inquiry: “the truth is out there.” The quest for truth is humanity’s big challenge.

All living creatures discern information from ambient noise. We humans create stories out of information and from the stories invent myths, models, and theories to derive meaning and utility. Careful analysis, by verification or scientific testing, pulls truth from facts, myths, models, and theories, nonetheless, truth remains elusive. The intersection of news and entertainment risks confusion and credibility as when the radio broadcast War of the Worlds in 1938 by Orson Wells created a minor panic for listeners who tuned in after its introduction as a radio play and thought that Martians were actually invading Earth. When trusted news anchors portray their roles in TV and film fiction they diminish their credibility. Worse, deliberate fake news tilts political opinion and instigates conspiracy fears that cannibalize civilized society by devouring trust that is the currency of civilized people.

 

Seven.          

Lapides copy 3

True facts. The story of Jack Lapides, former chief of urology here at Michigan, educator, and innovator (above) was briefly told in an obituary column his sister requested after he passed away. [New York Times. Nov 19, 1995] (The published version has a single typo, introduced by the newspaper that must have thought the reference to Charles Huggins was “Charles Higgins.”)  Jack’s surgical accomplishments continue to show up in urology clinics around the world, illustrating the long reach of an innovative surgeon. Surgeons fix problems, and one of Jack’s surgical innovations was the vesicostomy, a solution for bladder and sphincteric dysfunction by making an opening on the abdominal wall.

The concept and practice of urinary diversion preceded Lapides by many decades with the standard of care for neuropathic bladder in the mid-20th century consisting of suprapubic cystotomy, ureterosigmoidostomy, ureteroileostomy, cutaneous ureterostomy or nephrostomy. Lapides favored vesicostomy to eliminate urinary stasis, high pressures, and urethral incontinence, but standard ostomy devices were unreliable: “Initially, we employed the usual types of fecal colostomy devices for collecting the urine, but soon became disenchanted with the various appliances because of bulkiness, leaking of urine, skin reaction, malodor, and difficulty in changing the apparatus.”  [Lapides J, Boyd R, Fellman SL.  A urinary ileostomy device.  J Urol. 1958. 79:353-355.] Lapides created a device utilizing a rubber ring with changeable collecting condoms, being rapidly replaceable, streamlined and more acceptable to patients. As it gained popularity it came to be known as the Lapides urinary ileostomy. [Lapides J, Ajemian EP, Lichtwardt JR. Cutaneous vesicostomy. J.Urol. 1960. 84:609-14.]

Pediatric urologists utilize vesicostomy occasionally. Keith Schneider, pediatric surgeon in New York, and John Duckett, pediatric urologist in Philadelphia, subsequently described vesicostomy techniques of their own, but these were mostly replaced by Lapides’s clean intermittent catheterization methods after 1971 and the reconstruction approaches of W. Hardy Hendren. We honor the Duckett and Lapides names with lectureships here in Ann Arbor in July, as the first academic events of the residency training season. I carry the Lapides name with my endowed professorship and Hardy (mentor to John Park) continues to be an inspiration and friend to many of us in Ann Arbor.

 

Eight.

Intersecting story. Last year our departmental office got a call from Peggy Hawkins of Chevy Chase, Maryland, who identified herself as the sister of a former Lapides patient in need of help. Her brother, we can call Larry, was living in Florida and dependent on a vesicostomy Lapides created in June, 1968, but Larry was having trouble obtaining stomal supplies. Peggy, recalling the name Lapides, contacted our office for help. I called Larry and we got him in touch with our UM stomal experts who found some solutions.

Peggy called back recently to tell me that Larry recently passed away and filled me in on Larry’s amazing story. She assures me that Larry would have been pleased to share the following details of his life, particularly the importance of his vesicostomy to him.

Born in 1943, Larry was the only son in a family with two sisters. Popular and athletic, he played football and ran track in high school. After graduation from college with a major in political science he joined the United States Army as a Second Lieutenant and married his girl-friend. Larry was sent to Vietnam with the 173rd Airborne Brigade in 1967. The Tét Offensive changed his life. Launched on January 30, 1968 by 80,000 North Vietnamese and Viet Cong forces during the Tét lunar new year holiday, the offensive was a coordinated series of attacks on over 100 cities and towns in South Vietnam. A mortar round that first day exploded just behind Larry causing tremendous concussive injury to his back and spinal cord with extensive shrapnel injuries, particularly to lung, liver, and upper extremities. The triage officer didn’t expect him to live, but Larry defied expectations and survived first to the field hospital, then to a general hospital in Japan, and next to Valley Forge Army Hospital in Pennsylvania, but with paraplegia and consequent lower urinary tract dysfunction that translated to sepsis and upper tract deterioration.

Bronze star

His medical condition continued to decline at Valley Forge and around this time a son was born. Larry separated from the Army in June, 1968 and was sent to the Ann Arbor VA that month where he came under the care of Jack Lapides who understood the deleterious nature of high pressures in the neurogenic bladder who explained that vesicostomy might extend Larry’s life another ten years, Peggy recalled. The procedure that June turned around Larry’s deteriorating clinical course and provided him another 48 years of independent life without urinary tract problems as long as he had access to stomal supplies.

After recovering from the operation and stabilization of his health Larry enrolled in law school in the fall of 1969, living in a nearby apartment with reasonable wheelchair access. With his Juris Doctorate he moved to Florida in 1972 mainly because of the flat terrain and more favorable climate, finding work in politics early on as an advocate for Veterans in Tallahassee. Larry received a Purple Heart and Bronze Star (above) with a “V” Device (for valor) in 1974. In 1978 he ran for public office and served 4 terms (1978-1986) in the Florida House of Representatives where he chaired the Veterans Affairs Committee and impacted a groundbreaking generic drug law. He was elected Dade County Commissioner 1988-1994 and sponsored nation’s first family leave ordinance (Miami-Dade employees 1992), helped the Miami community recover after Hurricane Andrew and found creative solutions to the influx of Haitian immigrants in Jackson Memorial Hospital and Dade County Public Schools. Larry served on the Board of Vietnam Veterans of America. His network of political friends included Bill Clinton and Senator Tom Harkin, who introduced the Americans with Disabilities Act in the Senate. Larry’s son died at age 34 in 2002, leaving Larry 2 grandchildren – a granddaughter who teaches kindergarten and a grandson currently serving in the Army. His step-son works for the U.S. Secret Service.

During his 48 years with a stoma Larry was able to engage socially and professionally. Never in those 48 years did he have a UTI, upper tract problems, or stomal problems, although access to stomal appliances, necessary for daily peace of mind, became increasingly difficult as the market for them disappeared. Larry died recently from multisystem problems, but without urinary tract issues. He will be buried at Arlington National Cemetery.

 

Nine.

The Tét Offensive of 1968 continued through February. Although a military defeat for the North it intensified the American public opposition to the war and created a crisis in the Johnson administration. The “credibility gap” that had become apparent in 1967 widened in 1968, the year US casualties peaked with 16,592 soldiers killed. In February that year the US Selective service called for a draft of 48,000 men and on February 28 Secretary of Defense Robert McNamara stepped down from office. McNamara had been a long-time college friend of my UCLA urology professor Willard Goodwin and coincidentally lived in Ann Arbor for a short period as president of Ford Motor Company. As early as mid-1966 McNamara, as defense secretary believed that “there was no reasonable way to bring the war to an end soon” and that we should quickly find a political solution with North Vietnam and the Viet Cong. These were marginal opinions in the Johnson administration. [McNamara. In Retrospect. 1995. P 262] Many conspiracy theories abounded about the Vietnam War and some still resonate, but McNamara’s book lays out the story clearly, explaining the mistakes of management, failures of duty, and sins of pride led to escalation of conflict and flew out of control. The Fog of War. Lessons from the Life of Robert S. McNamara, a film by Errol Morris and a book by James Blight and Janet Lang, explains the cautionary tale.

 

Ten.

Chang Lecture.  Medicine without art is a commodity. Not to disparage commodities, we expect them to be dependable, available, and standard in quality. With health care however we prize human values of excellence, kindness, discernment, attention, discovery, innovation, and even virtuosity. For all of us as patients and families, our healthcare needs and expectations go beyond mere provision of commodities. Many services in medicine can be managed as commodities: blood pressure screenings, flu shots, blood draws, and dental hygiene are typical examples, although even these can be done artfully or not.  The routine blood pressure check requires thoughtful matching of cuff to body size and a few minutes of relaxation that puts the recipient at ease. Any human performance can be given with care, enthusiasm, and art – or not.

My aunt Evelyn Brodzinski, an artist, once said “Art is anything that is choice” after I asked her “What is art?” I quote her definition often. Art consists of the choices we make in the performances we give, whether delivery of a job, doodling on paper, whistling a tune, writing an essay, taking a picture, drawing a blood sample, or doing a surgical procedure. Any vocation can and should be performed artfully. Universities have a duty to propel this aspiration in all their fields of study, and the artful provision of healthcare should be at the top of any list of fields. The study of art is the study of choices in the world.

Gibbes

[Above: Lawrence exhibit Gibbs Museum, Charleston, SC]

We began the Chang Lecture on Art and Medicine in recognition of this obligation of our university. Such a lecture could just as easily come out of any of the 30 departments in our Medical School.  It could also have come from Michigan’s Department of Art History or School of Social Work. We brought it forward from the Department of Urology inspired by the linkage of art and medicine in the family of Dr. Cheng-Yang Chang, a urologist who trained and practiced at the University of Michigan, as well as founded a medical school in Taiwan and later practiced in Flint.  His father, Ku-Nien Chang was a famous painter in China and Dr. Chang’s oldest son is a urologist in Albany NY, trained here in Ann Arbor under Ed McGuire. Dr. Chang’s youngest son is a financial analyst in Chicago and one of UM’s best alumni supporters. This year Dr. David Watts, a prominent gastroenterologist in San Francisco and nationally-known humanist, will give the Chang Lecture July 20, 5 PM, Ford Auditorium.

AAAF 2016

[Life and the pursuit of happiness on Liberty. Art Fair. 2016]

 

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts June 2, 2017.

Qualification, adaptations, & stories

3876 words

 

 

One.  

             Ann Arbor’s redbud flowers  are now gone in June, Memorial Day is behind us, and summer is at hand. Redbuds appeared in April and stole the foliage show until other flowers appeared and trees leafed out. I saw the last redbud flowers in early May and by mid-May they were gone (above & below: Mike Hommel’s tree – also shown in our May posting). Redbud flowers, more of a magenta pink than red, are pollinated by long-tongued bees. Other bees are not so well-qualified, as their tongues are too short to reach redbud nectaries, the secretory structures at the base of stamens containing the food that attracts pollinators. Generalist bees forage among all flowers, but specialist bees with tongues over 5.5 mm work the deep nectaries. Since the first “Adam and Eve” bees 100 million years ago, the creatures adapted to changing environments by creating diverse successors, some of which survived better than others in their temporal milieus. A Science paper showed Colorado bumblebee tongues shrank nearly 25% in the past 40 years, adapting to changing alpine floral diversity, but putting long-tube flowers like the redbud (and foxglove, Indian paintbrush, clover, snapdragon, and bluebell) at risk. [N. Miller-Struttmann et al. Science 349:1541, 2015] The mutuality or co-dependence of bees and flowers is one of nature’s fine arts. [Consultation from beekeeper-urologist Brian Stork of West Shore Urology in Muskegon.] Qualification in the sense of fitness for a purpose, skill, or accomplishment, is at the heart of evolution, civilization, and our specialized world of healthcare.

On the human scale, we adjust graduate medical education to produce a diverse set of our own professional successors, anticipating that they will fit tomorrow’s health care milieu better than my generation could if we cloned ourselves. In the next few weeks graduating residents and fellows across North America will become “qualified” to practice medicine after completing formal training in their specialties, although ultimately they will need board certification. The faculty backup they initially required, became redundant incrementally over their 5-8 years of training, so that by now they are more like colleagues of their teachers than trainees. Medical training, most keenly focused at the GME level, has done well in preparing the next generation of doctors for careers as qualified specialists. Urology residents and fellows in Ann Arbor are well-qualified with diverse clinical, research, teaching, and leadership talents to fit the diverse healthcare environments they will enter. Above all we hope their professionalism and critical thinking skills will be at the forefront of their lives and careers as they pollinate their fields and communities.

Once qualified, health care providers face the challenge of keeping up with the changing knowledge, skills, and technology of modern healthcare. One effective way to do this is through professional meetings and for urologists the American Urological Association, this year in Boston, is center stage. The MUSIC reception and the Nesbit Society gathering were worth the trip just by themselves. Sunday’s opening plenary session featured Julian Wan, as associate editor, giving a Journal of Urology highlights presentation, our alumnus Barry Kogan (current chair at Albany) moderating three debates, and Dana Ohl leading a transgender discussion. I could mention at least 100 other presentations, posters, panel appearances, and other “visibilities” from UM to say nothing of those of our alumni, but the national convention is far too big to get to most venues.


[Nesbit reception at Moakley Courthouse. Above: Gary Faerber University of Utah, Bahaa Malaeb, Lindsey Hampson UCSF, Noah Canvasser UC Davis.  Below: Mahendra Bhandari – Vatikutti Institute, Khurshid Ghani, Meidee Goh, David Fry]

 

Two.

Education and medical practice were quite different 100 years ago as Russian physician-author Mikhail Bulgakov (1891-1940) relates in a story of a young doctor starting out during a cold autumn in rural Russia. The experience was likely similar in Europe, Africa, or the Americas until specialty medicine and formalized graduate medical education took hold. In a little more than 12 pages, Bulgakov tells a tale pulled from his experience in 1916 as a newly “qualified” doctor sent to a provincial town in revolutionary Russia. The young physician was terrified imagining his first medical crisis, for example, a patient might present to his clinic with an inguinal hernia, or even worse, a strangulated one. The doctor recalled observing only a single hernia repair as a student and even though surgical texts were at hand in his new office, he was well aware that he lacked any experiential knowledge: “‘I’m like Dmitry the Pretender – nothing but a sham,’ I thought stupidly and sat down at the table again.”

“The Embroidered Towel,” was one of 9 stories in Bulgakov’s collection A Country Doctor’s Notebook, written in the 1920s and translated into English by Michael Glenny in 1975. The story rings true to my experiences as a midlevel UCLA surgical resident rotating at San Bernardino Country Medical Center, pretty much on my own for general, orthopedic, and neurosurgical crises at night in the mid-1970’s. Bulgakov (above) began practice as a “qualified doctor” in a chaotic world buffeted by WWI and the Russian Civil War. His rural medical practice was cut short as successive governments drafted him as a physician, culminating with the Ukrainian People’s Army in February, 1919 sending him to the Northern Caucasus. After contracting typhus, he abandoned medicine for a writing career, as a journalist, playwright, satirist, and science fiction author. His early work was favored by Stalin, but later writing ran afoul of the Communist Party and one play, The Run, was personally banned by Stalin. Bulgakov’s satirical novel, The Master and Margarita, was published posthumously in 1966 by his widow. The author is said to have died of nephrosclerosis. The Master and Margarita has been the subject of films, mini-series, and a graphic novel rendering. A current book by physician Julie Lekstrom Himes, Mikhail and Margarita: A Novel, uses Bulgakov’s book as a platform for her own debut novel, set in 1933 Soviet Russia.

 

Three.

            The study of history needs no justification to educated people. Knowledge of the past may not perfectly predict the future, but provides clues, data, and wisdom to help find optimal pathways to the future.

The late pediatric surgeon and scientist, Judah Folkman (above) was a man of uncommon wisdom and he had this to say when we visited his lab in Boston with a group of students and faculty from Michigan’s Victor Vaughn Society: “If you don’t understand the history and mission of the organization in which you work, at some point you will feel exploited.” Folkman was paraphrasing his chief at the Massachusetts General Hospital, Dr. Edward Delos Churchill, from an internship lecture. The point, in a larger sense, is that it is essential to job satisfaction, in addition to quality work products, that workers understand the history and mission of the place where they work. For those of us in health care, and urology most particularly, our history and mission are inspiring. If someone misses this inspiration, they are somehow stranded in left field.

It is up to all of us in medicine to study and teach our past to our colleagues, to our successors, and to the public. History, however, is no fixed thing. Stories of the past are fungible – new facts turn up and these may or may not turn out to be true. As times change, reinterpretation of the past changes the old stories. Furthermore, all history is connected and no parochial histories, such as those of urology, can omit consideration of the rest of the world – and vice versa. Ian Thompson once proposed we write a book called How Urology Changed the World. This project remains on our bucket lists. By the way, Folkman’s chief, Dr. Churchill, was Mediterranean Theatre Commander for Surgery during WWII, establishing regional blood banks and air evacuation of the wounded. [ED Churchill. Surgeon to Soldiers. Lippincott Williams and Wilkins. Philadelphia, 1972.] [LS King. Book review. JAMA 220:595, 1972.]

 

Four.

D-Day anniversary is June 6. We shouldn’t forget that day in 1944, not only the particular day, but also the forces that led up to it, its incredible stories, and the world that followed. The politics, deployments, leaders, meteorology, weaponry, heroism, cowardice, teamwork, and duplicity constitute innumerable stories, stories that will change as new facts and analyses come into play and lead to a greater truth.

The iconic photograph above (called “Into the jaws of death”) was taken by Robert F. Sargent, Chief Photographer’s Mate. It shows disembarkation at Omaha Beach of Company E, 16th Infantry, 1st Army Division wading onto the beach at Fox Green Section about to encounter the German 352nd Division. German forces were commanded by General Rommel, who was away from Normandy that day because of his wife’s birthday. D-Day took the Germans by surprise and early signs of the invasion were discounted by Hitler, who was certain that Calais would be Eisenhower’s Allied Operation Overlord landing site. The American 1st Army, commanded by Omar Bradley, was responsible for both the Omaha and Utah Beach invasions. Two-thirds of Omaha’s Company E became casualties and of the 39 soldiers I count in the photograph, 26 would die or be seriously injured. Overall Omaha casualties were the worst among the 5 sectors that also consisted of Gold, Juno, and Sword under Canada and Britain. Allies landed 156,000 troops at Normandy on D-Day – 34,250 at Omaha. Only Juno and Gold linked up on D-Day, and it wasn’t until June 12 that all 5 beachheads consolidated. Allied casualties on D-Day were at least 10,000 with 4,414 confirmed dead, while German casualties were estimated at 4,000-9,000. If you have not visited Normandy, you should. Bradley was the last of America’s nine 5-star generals. I knew him briefly at the end of his life when I was at Walter Reed Army Medical Center.

 

Five.

The Pointe du Hoc speech of Ronald Reagan at the 40-year D-Day anniversary was mentioned last month in this posting. This speech was novel for its use of personal stories of D-Day to make that moment in time poignant to the audience. Individual stories build persuasion through ethos, pathos, and logos. My daughter Emily, when she was a Ph.D. student in English, instructed me repeatedly in those three classic modes of rhetoric and I’m finally starting to appreciate them. A story is persuasive when it comes from a credible source (ethos), if it appeals to sympathetic emotion (our mirror neurons yielding pathos), and if the narrative makes sense (logos). The audience must reasonably accept the story and storyteller as believable and honest, as well as agree with its observations or conclusion. Of course not all stories are authentic, although it is expected that the stories and histories of medicine are genuine.

“The United States Army’s clinical histories of medical practice during the Second World War form a significant addition to the literature of medical history,” Quinn H. Becker, Surgeon General of the U.S. Army, wrote. Those words were the introduction to the urology volume, edited by John F. Patton, in Surgery in World War II, produced by the Medical Department of the United States Army. My friend and former fellow here at Michigan, John Norbeck, gave me this book when it came out 30 years ago. [John F. Patton, Ed. Medical Department, Unites States Army. Surgery in World War II. Urology. Office of the Surgeon General and Center of Military History Unites States Army. Washington, DC, 1987.] Becker’s predecessor as Army Surgeon General was Bernhard T. Mittemeyer, my former commander at Walter Reed, fellow urologist, and friend who most recently served as president of Texas Tech University.

Six surgeon general’s later the name Eric Schoomaker pops up for the Army Surgeon General term of 2007 – 2011. Eric was a UM undergraduate who then completed UM Medical School with an additional Ph.D. in genetics. He undertook residency and fellowship in hematology at Duke followed by a distinguished Army career. Eric was our Medical School commencement speaker in 2012, when Jim Woolliscroft presided as dean. UMMS graduation is a major milestone for students and their families and it is also a meaningful ceremony for faculty – when else do you get to recite the Hippocratic Oath in sync with your colleagues? I had to miss it this year due to concurrence with the annual meeting of the AUA and Nesbit Alumni reunion. This year Francis Collins was UMMS commencement speaker, who was also linked to UM Department of Human Genetics as a faculty member under the great Jim Neel. The Collins address featured him singing on the guitar.

 

Six.    

            Cornelius Ryan brought D-Day and urology together for me. This Irish journalist covered WWII and turned his reporting into three excellent historical accounts, The Longest Day (1959), The Last Battle (1966), and A Bridge Too Far (1974). When I was a urology resident at UCLA I helped care for a 50-year old patient with metastatic prostate cancer when Ryan’s personal and similar story with the disease was published. Ryan had been diagnosed just he was struggling to begin writing A Bridge Too Far. He had seen a NYC urologist for lower urinary tract symptoms, a prostate nodule was detected, and biopsy was performed. Ryan returned to the office on Fifth Avenue, July 24, 1970 to get the results when the urologist informed him that the biopsy showed prostate cancer and radical prostatectomy was the only hope for “cure.”

“The doctor wants me to have the prostatectomy next week. Such urgency appalls me. I cannot make that crucial decision without more time. Professionally, I have never accepted a single piece of historical data without researching it to the fullest, collecting all the opinions and interviews I could.”  [A Private Battle. Published posthumously with Kathryn Morgan Ryan. New York City, 1979. p, 22. Simon & Schuster.]

Ryan wanted more of an explanation, but his questions were rebuffed. Home in Connecticut later that day he began a series of dictations that included the quote above, but never shared these with his wife. Ryan visited experts around the world and obtained more studies and advice, before returning to New York and discovering Willet Whitmore, for whom he developed great admiration and trust. Ryan began radiation therapy at Memorial Sloan Kettering that autumn, yet the cancer spread and continued to disseminate in spite of drug therapy. Kind and compassionate care was evident in interactions with Whitmore and most other physicians, but the initial condescending urologist, botched handoffs, institutional smugness, and healthcare disparities Ryan witnessed, are reported in sharp contrast. Over the next four years, as he struggled with spreading prostate cancer, Ryan completed his book.

After Ryan died in 1976 his widow, Kathryn Morgan, found the tapes in his desk.  She had them transcribed, interspersed her own observations and diary notes, and then published the account in 1979 as A Private Battle. I can’t recall how I came to know of the book, but I read it around that time. Somewhere along the line between UCLA, Walter Reed, and the University of Michigan I lost my copy, but after my own radical prostatectomy in 2014 I thought of Ryan, tracked down the book, and re-read it. A Private Battle contains meaningful lessons on health care and rekindled my curiosity about WWII, leading me to Ryan’s other books, followed by Steven Ambrose’s account of Eisenhower, Soldier and President and the newer biography by Jean Smith.

The Ryan papers ended up in the libraries at Ohio University. [Above: Cornelius Ryan at his desk. Photo and copyright by Eugene Cook.]

 

Seven.

Eisenhower, one of the great generals of history, detested war and recognized the necessity of international cooperation for peace. The deliberate restructuring of Europe after the war, management of tensions with the Soviet Union, and construction of the European Union were meant to bring stability and peace to the world. Peace, however, has been illusive in much of the rest of the planet and furthermore the postwar structures in Europe are unraveling.

Like most of us, Eisenhower had health issues. A knee injury altered his career path and turned him from a high-level football player to a remarkable coach, influencing his ascent to leadership. He began to smoke at West Point, largely as an ironic challenge to the authoritarian nature of the school and became a chain smoker throughout most of his career, particularly during WWII. After the war his doctor told him to quit smoking and he did, “cold-turkey.” Recurrent ileitis, Crohn’s disease, troubled him throughout life. Although he complained minimally, several hospitalizations and one operative procedure were necessary. As a resident I would learn about the “Eisenhower procedure,” namely a bowel resection for localized Crohn’s disease. During the White House years, Eisenhower’s physician was Howard Snyder, the grandfather of my friend and colleague Howard McCrum Snyder at Children’s Hospital of Philadelphia. The younger Snyder recalls going to the White House swimming pool with his grandfather to swim with the president. Eisenhower’s cardiac issues were significant later in his life. A book by Clarence Lasby discusses the 1955 heart attack and makes judgments about Snyder’s management and the concealment of the illness, thoughts that rely on today’s standards of care and transparency. [CG Lasby. Eisenhower’s Heart Attack. How Ike Beat Heart Disease and Held on to the Presidency. University Press of Kansas. Lawrence KS, 1997.] But for Dr. Snyder, Nixon might have had his turn as president before JFK.

 

Eight.

 Since Eisenhower’s days medical practice has changed and tools to address heart disease are enormously different. Eisenhower had bed rest, the EKG, and digitalis. Today we have an armamentarium of medications, surgical bypass, replacement parts, stents, TAVR, electrophysiology ablations, and heart transplants. The scientific cocoon of 21st century medicine is countered by local workplace problems. These may be matters of patient access, bed capacity, EHR problems, technology constraints, and billing and coding issues.

Although painful for us on the frontline of health care, they are “first world problems” that come into perspective when considering the rest of the world. Journals such as The Lancet frame the global perspective. For example, a recent paper examined the hypothesis that better cook stoves might prevent pneumonia in children under 5 years old in rural Malawi.  Unfortunately, the study (a cluster randomized controlled trial) found no benefit. What stuck in my mind, however, was the opening statement of the paper.

“Almost half the world’s population, including 700 million Africans, rely on biomass fuels for cooking (e.g. animal dung, crop residues, wood, and charcoal)… Biomass fuel is typically burned in open fires, often indoors, leading to high levels of air pollution from smoke.”  [Mortimer K, Ndamala CB, Naunje AW et al. A cleaner burning biomass-fueled cookstove. The Lancet. 389:167-175, 2017.]

While we dither in our journals and at our professional meetings over trivial first world issues, such as the virtues of robotic surgery versus open surgery or HIPPA compliance in electronic health records, half the world cooks its meals on open fires using dung or other biomass fuels.

Bulgakov brings us closer to that other world. He served his patients to his technical limits, but insecurity due to the inadequate knowledge and tools of his time as well lack of good professionalism role modeling left him abrupt and authoritative to patients and families. Fifty years later the Fifth Avenue urologist of Cornelius Ryan was no kinder. Kindness and consideration of patient preferences are fundamental to the concept of the good doctor, however it seems to have taken federal regulation to drive that sensibility home as MACRA and CAHPS link professional compensation to evaluations by patients.

 

Nine.

Case reports. Bulgakov’s stories are narratives of actual cases or extrapolated patient experiences and we may never quite know where fact ended and imagination or “artistic license” took over. It doesn’t really matter, because the stories ring true and are constructed artfully although presented as “stories” rather than clinical case reports. Imbued with experience and fact, they are intended as fiction and we judge them accordingly, but well-crafted fiction can illuminate reality, honing a story well enough to let the reader glimpse a portion of the real world and the human condition with greater acuity than before the reader encountered the story. The judgment of whether Bulgakov’s story was true or imagined is not necessarily essential to readers a century later. If the story rings true and we find meaning (and art) in it, then the author has done a good job. Other physician writers have continued this genre, artfully using clinical experiences and stories to expand consciousness and discover truths about ourselves. David Watts, our Chang Lecturer on Art and Medicine next month, is part of that tradition.

Stories intended as clinical narratives, on the other hand, demand absolute truth in the narrative. This is a bedrock expectation. Truth matters greatly in the real world of clinical medicine and in the academic reporting that surrounds it. A clinical story assumes scrupulous adherence to the facts of the matter and, if presented artfully, the report can have great meaning for the reporter and the readers. The value of a good clinical story is neither necessarily less or greater than the value of a reported clinical experiment, series, trial, or metastudy. Scientific experiments or larger clinical studies may ultimately be true or false, but clinical stories will likely remain durable narratives, unless the story was inaccurately reported or its substance misinterpreted. Some iconic scientific studies such as Mendel’s seeds or Semmelweis’s antisepsis experiment remain iconic and continue to instruct new generations of students. The clinical experiences of Morton with anesthesia, Lister with open bone fractures, or Annandale with successful orchiopexy were presented initially as stories – but they were stories that changed the world.

 

Ten.

Truth is also an expectation in academic humanities and journalism, although it is perhaps more fungible. Political perspective matters and it can put a spin on things. In the Soviet Union, truth was expected to emanate from the political leadership and this paradigm distorted the science, economics, agriculture, and indeed all parts of the nation. For example, the political imprimatur that validated the beliefs of Soviet agronomist Trofim Lysenko had enormous negative consequences for the health and welfare of his nation. [Loren Graham. Lysenko’s Ghost. Epigenetics and Russia. Harvard University Press, 2016] As we approach our big national holiday next month, it’s worth reflecting that the Declaration of Independence is remarkable in human history for liberating people as individuals from governments ruled by particular ideological, religious, or political paradigms. Representational democracy, imperfect as it is, remains mankind’s best hope toward a just, peaceful, cosmopolitan, prosperous, and sustainable world. This is the world that civilized people want to leave behind – a world somewhat better than we found it, granting that sometimes the prospects for this hope seem dimmed. We can tell our stories as historians, biographers, scientists, or journalists. Or we can tell them as artists, philosophers, or fabricators. It is important to discern the difference and to teach that discernment to our successors. Whether by trachea and tongue, pen and paper, or keyboard and internet, stories knit the human fabric together and truth is the ultimate arbiter. Don’t expect data to replace stories, you can support or refute stories with data. You can build stories out of data, perhaps someday using artificial intelligence in robots. But authentic stories will most likely always come from authentic humans.

 

Postscript

Once the redbuds faded away, the dogwoods (more easily pollinated) and other flowers stepped up their games of attraction.

[Above: dogwood. Below: Bee tongue photo from photomicrography.net, amateurmicrography.net http://www.flickr.com/photos/joeheath/5122105785/]

Thanks for reading What’s New/Matula Thoughts this June, 2017.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor