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

March Thoughts

DAB What’s New March 3, 2017

March Thoughts

3741 words

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

 

the_victors_sheet_music

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

or

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

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

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

louis_elbel

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

march

 

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

cave_painting_l

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

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

the-she-wolf

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

 

Three.

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

george_w-_johnson_1898

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

berlinerdisc1897

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

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

jackie_brenston-1

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

 

Four.

1949_oldsmobile_88

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

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

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

 

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

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

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

440px-muenchhausen_herrfurth_7_500x789

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

 

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

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

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

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

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

 

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

sterns-2012

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

 

Eight.

metro

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

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

 

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

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

 

Ten.

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

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

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

————————————————————–

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

734-232-4943

dabloom@umich.edu

 

February, Sunday feelings, and Monday facts

DAB What’s New February 3, 2017

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

 

icicle

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

korlebu

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

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

casey-perc

[Casey at bat.]

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

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

table-epipen

 

search
Two.

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

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

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

 

Three.

iran-blizzard

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

“ ‘Oh, Lincoln Forstner,’ said the noseless story-teller, ‘what is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine? You may even ask which is the more intense craving and pleasure: to drink or to make water. But in the meantime, what has been done? A song has been composed, a kiss taken, a slanderer slain, a prophet begotten, a righteous judgement given, a joke made…’ ”  [Isak Dinesen. Seven Gothic Tales. The Dreamers. 1934, Random House. P. 275.]

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

karen_blixen_and_thomas_dinesen_1920s

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

 

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

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

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

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

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

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

 

Five.

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

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

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

chromosomes

[Chromosome 15]

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

 

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

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

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

 

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

400px-charles_darwin_photograph_by_herbert_rose_barraud_1881

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

lincoln-warren-1865-03-06-jpeg

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

 

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

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

luca

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

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

 

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

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

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

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

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

 

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

currier-ives

wilkes_booths_deringer

rimfire-cartridge

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

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

600px-booth_escape_route-svg

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

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

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

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

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

 

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

 

 

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

2017 is here

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

 

grand-rounds

One.

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

galens

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

holiday-party

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

fac-mtg

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

 

 

Two.

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

washington

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

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

Washington set the tone in the opening sentences.

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

The conclusion was optimistic.

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

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

 

 

Three.

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

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

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

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

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

tim-johnson

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

 

 

Four.

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

runge-cantor

 

 

Five.

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

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

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

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

 

 

Six.

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

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

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

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

 

 

Seven.

hamilton

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

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

ham-board

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

mike-clarence

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

ben-team

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

 

 

Eight.

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

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

orson_welles_war_of_the_worlds_1938

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

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

 

 

Nine.

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

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

fifth

————————————————–

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

stats-mid-dec

[Above: MatulaThoughts analytics in mid-December]

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

 

 

Ten.

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

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

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

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

hew-seal

[Above HEW seal; below HHS seal]

hhs-seal

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

 

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

Matula Thoughts December 2, 2016

Politics, nutcrackers, and earthly delights
3799 words

One.

election-2016-copy

This has been a year of political surprises with Brexit, the Columbian failure to reconcile with FARC, and the American presidential election. The weekend after our election I happened to be at the Fourth Quinquennial John W. Duckett Festschrift at the Union League of Philadelphia. This venerable institution was founded in 1862 as a patriotic society to support the policies of Abraham Lincoln, whose ideas seem so obvious and mainstream today, but they split the United States nearly permanently at that time. In a Union League reading room you see our friend and colleague George Drach contemplating the meaning of the election for healthcare. Just this past summer George spoke at our Duckett/Lapides Symposium on the implications of the MACRA law, passed earlier this spring with strong bipartisan support. Whether or not the Affordable Care Act (ACA) and MACRA disappear, healthcare policy, regulation, and economics are going to get evermore contentious and confusing. Politics may be easy to distain, but they surround us and shape our lives. This milestone day, December 2, is worth recalling for two examples of politics and ideologies that led nations and people sadly astray.

First example: red scares. The Cold War, following WWII, instilled legitimate anxiety over the spread of communism in the West where scoundrels capitalized on that fear and created the Second Red Scare (1947-57). A First Red Scare (1919) followed WWI and the Bolshevik Revolution of 1917. Both phenomena occurred during times of patriotic intensity and exploited fears of communism. The second scare lasted far longer than the first and came to be known as McCarthyism after its central figure Joseph McCarthy, US Senator from Wisconsin.

herblock1950

[Above: Herblock cartoon March 29, 1950 Washington Post, introducing the term McCarthyism.] Paranoia crossed the United States from Washington to Hollywood and left its effects in Ann Arbor, where 3 faculty members were dismissed by the University for refusing to testify to the House Un-American Activities Committee (HUAC). Mark Nickerson (UMMS Pharmacology), H. Chandler Davis (UM Mathematics), and Clement Markert (UM Biology), suspected of membership in the Communist Party, were called to Lansing on May 10, 1954 to testify before an HUAC sub-committee. The professors refused to answer certain questions, claiming Fifth Amendment privilege, and UM President Harlan Hatcher promptly suspended them pending a faculty inquiry related to “intellectual integrity.” Nickerson was fired out of concern that he was damaging the reputation of the Medical School and University. He went on to a distinguished career in Canada. Davis was also fired and later served jail time for contempt of Congress. Markert was retained but left UM soon thereafter. While this breech of their civil rights passed public muster in the Red Scare fervor, the breech of their tenure rights (Regents bylaw 509) tripped up the university and caused an academic firestorm. The American Association of University Professors would later ask the UM to make “a significant gesture of reconciliation” and that became the annual Davis, Markert, Nickerson Lecture on Academic and Intellectual Freedom. [James Tobin. Seeing Red. Medicine at Michigan Spring, 2009; 11:14-15] That second Red Scare began to wind down later in 1954 on this day, December 2, when the United States Senate voted 65 to 22 to censure McCarthy for “conduct that tends to bring the Senate into dishonor and disrepute.”

castro

Second example: smoke and mirrors. On this day in 1961 Fidel Castro, in a nationally broadcast speech, announced that Cuba would adopt Communism, surprising us in the north and setting off a chain of events with the Cuban Missile Crisis the following year that nearly brought the world to nuclear confrontation. A recent book by former Secretary of Defense William Perry (My Journey at the Nuclear Brink – mentioned here a few months back) offers a frightening account of that time and a more frightening preview of the world ahead of us now. While Castro’s iron grip endured for a half century his ideological experiment failed and he died just 7 days ago. Venezuela under Hugo Chavez tried to reprise the Cuban experiment, but that too didn’t turn out well for its people. Chavez died in 2013 after treatment in Cuba for unspecified malignancy. Both dictators rode waves of populism in their countries, where celebrity ideology support them even to this day, in spite of the economic and social disintegration they left behind, showing once again that populism usually turns out poorly for the populace at the end of the day. [Picture above: Wikipedia]

 

 

Two.

colors

Autumn colors peaked late this year, reaching well into November in Ann Arbor even past election day. After a nontraditional election season the people spoke and the transition of power is following its honorable historical precedents. What this will mean in terms of health care remains to be seen. The ACA will be problematic to unravel and, with it or without it, deployment of fair and excellent health care, the mission of academic medical centers, and the stability of the health care industry are at risk regardless of whatever party dominates the day. Healthcare has been a hard nut to crack in America and a viable menu of choices for its deployment remains elusive.
The University of Michigan urology microcosm, however, seems reasonably in balance. Last month we completed residency application interviews for more than 60 prospective trainees. The four to match here will begin their 5 years of residency in July of 2017 and graduate in 2022. [Above Medical School foliage. Below view from Bank of Ann Arbor headquarters]

baa

Last month was also notable for its super supermoon (below). The moon’s orbit came so close to the earth that it was larger and brighter than any time since January 26, 1948. Having missed it back then, I took the picture below on November 12. To a lesser degree supermoons occur every 14 months when a full moon occurs at its perigee (closest encounter). More periodically the moon’s oval orbit elongates to create the super supermoon effect.

supermoon

Michigan Football’s last home game was an exciting victory over Indiana, bringing the first seasonal snowstorm in the fourth quarter when we also saw snow angels on the field during time outs.

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[Above: first quarter. Below: fourth quarter from Sincock suite]

snowy-4th

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The season ended a week later with an unprecedented double overtime loss in Columbus.

 

 

Three.
We shouldn’t leave 2016 without mentioning once again, Jheronimus van Aken, the Flemish painter known as Hieronymus Bosch who died 500 years ago. His Garden of Earthly Delights, a triptych in The Prado, depicts strangely imagined hedonistic days of mankind between the Garden of Eden on the viewer’s left and the Last Judgment on the right. Bosch painted the work around 1497, which for historical perspective was five years after Columbus landed on a Bahamian island and claimed the adjacent continent of diverse people, flora, and fauna for the King and Queen of a nation thousands of miles away.

el_jardin_de_las_delicias_de_el_bosco-1

Bosch also painted a strange work called The Wayfarer, mentioned here last month for its stranguria depiction. The world of Hieronymus Bosch around 1500 was probably a pretty grim place, although not devoid of earthly delights, as he imagined in his triptych. A later triptych, The Last Judgement (c. 1527) by another Dutch artist Lucas van Leyden, depicts the actual day of judgment in the middle panel flanked by heaven on the left on hell on the right.

van-leyden

The times of Bosch and van Leyden were framed by fierce religiosity that juxtaposed nations and perpetrated conflicts negating the very values of the religions. Earthly delights, in the minds of those artists and most of their contemporaries, were only a brief interlude before the Heaven and Hell that defined mankind. Native Americans, suffering the European invasion, had no pretension to those ecclesiastical visions of heaven and hell, but rather sought to make the most of their experiential present, albeit with respect to their forefathers and the spirits of their present-day world. It was quite a contrast of civilizations and the Europeans surely brought dimensions of ecclesiastical and actual hell to North America.
Ecclesiastical visions have rightly become personal matters in most of western society. The separation of church and state, as espoused in The Constitution, was a forward step in the self-determination of mankind, although it remains under constant challenge at home and abroad. If The Garden of Earthly Delights is all we can expect in life (before Heaven or Hell) then it should be fair and just, and health care is central to the mix of basic expectations.

 

 

Four.

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After viewing van Leyden’s triptych at the Rijksmuseum in Amsterdam early this autumn, while en route to a pediatric urology meeting, I was stopped in my tracks by street musicians playing an enchanting soft tuba staccato note that morphed into the familiar beginning of Vivaldi’s Concerto No. 4, “The Winter.” It hardly felt like winter at the moment, but it was a beautiful interlude. Known as The Red Priest (Il Prete Rosso) Antonio Vivaldi wrote The Four Seasons around 1723 and published it in 1725, coincidentally in Amsterdam. Vivaldi clearly was familiar with the nastiness of freezing rain and treachery of icy paths as seen in the narrative that accompanied his piece (below).

Allegro non molto
To tremble from cold in the icy snow,
In the harsh breath of a horrid wind;
To run, stamping one’s feet every moment,
Our teeth chattering in the extreme cold
Largo
Before the fire to pass peaceful,
Contented days while the rain outside pours down.
Allegro
We tread the icy path slowly and cautiously,
for fear of tripping and falling.
Then turn abruptly, slip, crash on the ground and,
rising, hasten on across the ice lest it cracks up.
We feel the chill north winds course through the home
despite the locked and bolted doors…
this is winter, which nonetheless
brings its own delights.

Winter Solstice will be here soon (December 21) and after that interlude of shortest daylight, each passing day will be a step closer to spring, in spite of “the harsh breath of a horrid wind.”

 

 

Five.
Mirror neurons again. Since I read John Berger’s A Fortunate Man last summer, Dr. John Sassall and his deep empathy for his patients in an impoverished English hamlet have haunted me. The lives of those people in the mid 1960s were perhaps not so far removed those Bosch depicted across the North Sea before the Industrial Revolution. While Sassall may seem hypersensitive, he was not so different from the rest of us but for our lesser imaginations. The journalist’s impressions of Sassall’s thoughts are worth repeating.

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

lange

[Classic photo of Dorothea Lange. Destitute pea pickers in California – mother of 7. 1936. Library of Congress.]
My daughter Emily, a young English professor at Columbia, teaches Aristotle’s three methods of persuasion: ethos, logos, and pathos. Visual art, Dorothea Lange’s photography for example, captures the suffering that troubled Sassall so greatly and should trouble us too. We are insulated from pathos by the professional boundaries of ethos and the logos of our science, metrics, and computers. The grim thoughts of Sassall stretch the role of a physician. Yet, who in society has a greater mandate to defend mankind’s well-being specifically and generally? Clergymen, teachers, and rare politicians share this charge, but day-in and day-out, healthcare providers are most consistently on the front lines with some of the best tools to ameliorate the daily pains and continual diminutions of individuals around us. Urologists and other specialists may claim turf protection, but can’t forget that they are physicians first and foremost. Berger’s last sentence was most likely targeted to the difficult days at end-of-life, the time when the garden of earthly delights has run out – familiar terrain for most urologists.
The toll of pathos was considered by Jennifer Best, from the University of Washington in Seattle in A Piece of My Mind column in JAMA called The Things We Have Lost [JAMA 316:1871, 2016].

“When most people consider the grief endured by physicians in training, they look first to the devastating narratives of patient care – sudden illness, agonizing decline, putrid decay, untimely death, haunting errors, and crushing uncertainty. Even more than a decade from residency, I am pierced by these tragic moments and faces – each still heart-shatteringly vivid.”

Best goes on from this opening statement to suggest not only confronting these griefs in “curricular endeavors” such rounds or narrative sessions with trainees, but also considering personal losses as we play out our roles in what she calls physicianship. Her claim is that when we accept the role of healthcare provider, we step into a new identity and lose some of our freer, ad lib, selves. Growing our sense of empathy, yet maintaining resilience is the challenge. Best rejects counter arguments that her considerations are “first-world problems” or that because “it could be so much worse” we need not be overly concerned with professional fragility. Her column offers a good footnote to A Fortunate Man.

 

 

Six.
Department of complaints. We spoke last autumn at some length on medical error and argued that our profession can never be free from it. Error is a fundamental property of life and intrinsic to all its processes. We study error in healthcare to minimize it and fortunately most error is nonlethal, although even when trivial it can hurt. The University of Michigan Health System, like any large scale enterprise, has many processes susceptible to error. With 2 million ambulatory care visits and 50,000 major surgical procedures yearly countless opportunities arise for untoward events ranging from missed blood draws to serious complications in ICUs. Every complaint is a gift, of a sort, providing opportunity for improvements in individual actions, processes, and structures. I recently heard complaints that targeted team leadership factors and the “hotel” functions of hospitalization.
Complaint A. Who is my doctor? Patients generally are thankful about their care from the doctors, nurses, and other members of the team, however fumbled handoffs or inability to identify the responsible member of a healthcare team on any given day are vexing. You can find analogies for this in baseball or air travel industries where the buck stops with the general manager of the team or the pilot. Both endeavors, like health care, require complicated teams, but each fan or traveler can usually identify who is in charge. Health care teams and systems need to make their ladders of responsibility more visible.
Complaint B. Must I share a room? Double room occupancy at UM Main Hospital is a vestige of an older era of health care, but is no longer acceptable for a variety of reasons including privacy, infection control, safety, comfort, and patient satisfaction. Our failure to convert the remaining double rooms over the past 20 years is an embarrassment today and correction is in the works, but  it’s nearly a billion-dollar fix including a new patient tower estimated to open in 2021.

 

 

Seven.
MACRAnyms. Acronyms abound in most occupations and populate the shop talk that distinguishes workers from the public at large. The big acronym for health care in 2017 is MACRA – the Medicare Access and CHIP Reauthorization Act of 2015. Sponsored by Congressional Representative Michael Burgess (R-TX-26) this act removes the sustainable growth rate methodology for the determination of physician payments and extends aspects of Medicare and the State Children’s Health Insurance Program (CHIP). I can’t pretend to understand this large and complex set of regulations outside of a few salient details, but fortunately we have experts among us at Michigan such as Tim Peterson (below – Medical Director Population Health Office UMMG). Like many well-intended public policies, unintended consequences are inevitable in MACRA, so the better we educate ourselves the more capable we will be to help patients lost in the regulatory shuffle and the greater likelihood we will have to protect the mission and values of healthcare education, clinical delivery, and research.

peterson-tim

 

MACRA attempts to displace the dominant model of physician payment from fee for service (FFS) to payment for value. While it is fashionable to vilify the motivational factors of FFS as a driver of health care expenses (and presumably unnecessary services) there is risk in terms of motivating the restraint of healthcare services. I also recognize a healthcare safety net is direct of a civilized society; universal access to health care is in the national interest. I equally recognize the downside of a system that does not reward work in terms of time and quality.
The intent of MACRA in shifting payment from FFS to payment for quality and value, set by complex government formulas, is an unproven experiment. Market forces should largely determine value and quality, while professional organizations should set basic standards for services. National healthcare cannot be left exclusively to the invisible hand of the market or the heavy hand of government. Healthcare affects everyone, employs one in six people in this country, and is a huge piece of our economy. The present systems of healthcare (there is no single “system”) need huge improvement, but changing it on a massive scale can be dangerously disruptive.
We need various systems of healthcare in simultaneous play, from the private and the public sectors to provide equity, excellence, innovation, and value. The private sector can best supply competition, value, innovation, and stakeholder responsiveness. The public system can best supply the safety net, equity, rules, education, and research. No single system, set of laws, organization, or paradigm can do it alone and we must be suspicious of any grand “answer,” for healthcare is a very hard nut to crack.

 

 

Eight.

nutcrackercollection
The nutcracker comes to mind at this time of year – not for the compression of urologic structures by the superior mesenteric artery and aorta, but for the ballet based on ETA Hoffmann’s story in 1816, Nutcracker and Mouse King. [Above: Nutcracker collection. Wikimedia Commons] The original story featured a nutcracker whose jaw was broken by an unusually hard nut, triggering political intrigue, revenge, hate, battle, and murder. Alexandre Dumas in 1844 lightened and popularized the story as The Tale of the Nutcracker, that became the basis for Tchaikovsky’s ballet in 1892. It is a rare American community in December where you can’t find an amateur or professional version to attend. You can read a synopsis of the morbid original story in Wikipedia (and perhaps give a modest annual contribution to keep that great public good afloat).
Our own great cardiologist, Kim Eagle, years back as editor of the NEJM section Images in Clinical Medicine, published a classic image of a 52 year-old woman with mild episodic gross hematuria from renal vein compression by the superior mesenteric artery. [Kimura & Araki. NEJM. 335:171, 1996] Improved CT technology offers a better image (below) in a more recent paper from the Mayo Clinic Proceedings. [Kurklinsky & Rooke. Mayo Clinic Proceedings 85:552, 2010]

nutcracker

[Computed tomographic venogram: nutcracker phenomenon.
Distended left renal vein (black arrow) compressed between
aorta and superior mesenteric artery.]

 

 

Nine.
Nutcracker politics continue to play out in life and art. The innovative House of Cards on Netflix is a very dark modern political nutcracker story. People need politics, crave leadership, and tolerate a fair amount of nut cracking.

house-of-cards

Ideology and celebrity can hijack brains like zombie viruses resulting in political choices and actions that prove contradictory to an individual’s ultimate interests. Politics, a term derived from the Greek “of citizens”, is the process of decision-making and governance of stakeholders. Political systems are frameworks that define acceptable political methods in a given society. Confucius, Plato, Aristotle and countless other thinkers have advanced political thought throughout the history of mankind. Formal politics prescribe public elections, national healthcare policy, and self-government as in our UM Health System. Informal politics are at play in all human activities, real and fictional, even as portrayed in The Nutcracker or House of Cards, where acceptable political methods get conveniently perverted to attain political power.

Politics, whether played fairly or unfairly, are essential to operationalize democracy, which is more of a biologic phenomenon, perhaps akin to quorum sensing, than an ideology or mere political system. This amazing universe of possibilities has arisen from 23 pairs of human chromosomes, their 3 billion base pairs, and 21,000 genes. Civilization is a house of chromosomes.

 

 

Ten.
Political parties developed to create candidates for public elections since the days of our first and last politically independent president, George Washington. Our present bivalent political system dates from 1854 when the USA has had two main parties, the then-dominant Democratic Party and an upstart party of anti-slavery activists, modernizers, ex-Whigs, and ex-Free Soldiers. The upstarts coalesced into a Republican Party that held its first official convention in Jackson, Michigan July 6, 1854. Within 4 years Republicans dominated all northern states and in 1860 they won control of both houses and their candidate Abraham Lincoln was elected president. He had a tough presidency and many expected little of him, but Lincoln rose to the occasion of the office and the issues of the day. Two years into his single term, the Union League of Philadelphia was founded. One room (below) features portraits of every Republican president of the United States.

repub-pres

Democratic and Republican parties dominated the American political landscape since Lincoln’s time, while other parties have failed to gain leverage. The Constitution, Green, Libertarian, and other small parties continue to field candidates but attract only small numbers of followers. Candidates for office independent of political party are not uncommon in local elections, but rare in higher office. Washington was the last independent president. Bernie Sanders is the longest serving independent in the history of the US Congress, although he aligns with Democrats. The Socialist Party of America, founded in 1901, never produced much of a winning ticket and dissolved in 1972. The Communist Party USA founded in 1919 was closely tied to the US labor movement, but never gained enough foothold to even have warranted the Red Scares; examples of its failed experiments near to us and in distant nations have dispelled serious interest in modern literate nations.
The 2016 election is over. Democrats will need to reconcile with Republicans and vice versa. The voting closely split the country and each party needs to learn from the other. More importantly both parties need to govern effectively, wisely, cooperatively, and justly. Health care policy is a muddle in the middle of things. Ultimately, though, what really matters above all is financial world-market stability and geopolitical stability. Without these, little else remains, so as with every president – we hope for the best.

political-promises-copy

[A cautionary slogan for politicians: Glen Arbor Fourth of July Parade, 2012 – Decker’s septic pumping truck with slogan: “another truckload of political promises.”]

 

Thanks for reading Matula Thoughts this first Friday in December, 2016 – and best holiday wishes.

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

Matula Thoughts October 7, 2016

DAB What’s New Oct 7, 2016

 

Education, errors, & box scores

3931 words

giants-vs-cardinals

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

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

640px-jetererror

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

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

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

mcguire-lecture

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

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

varbedian-students

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

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

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

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

hamdy

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

nesbit-group

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

coxs-wisc-game

[Clair & Clarice Cox tailgating]

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

montie-thompson

[Ian Thompson, Jim Montie]

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

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

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

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

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

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

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

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

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

Alice: ‘How long is forever?’

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

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

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

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

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

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

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

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

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

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

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[Jean Mohr photo p. 50]

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

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

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

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

[John Shook on right with Jack Billi]

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

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

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

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

henry_chadwick_baseball

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

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[1876 Box score: Wikipedia]

 

 

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

codman

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

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

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

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

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

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[Michigan 14 – Wisconsin 7,  Nesbit Weekend 2016]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts August 5, 2016

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Matula Thoughts – August 5, 2016

 

Summertime field notes, superheroes, and retrograde thoughts.
3975 words

 

Art Fair

Patient experience. Walking through the Art Fairs last month after great lectures from visiting professors, my thoughts wandered to Matula Thoughts/What’s New, this electronic communication that has become my habit for the past 16 years. It may be presumptuous to think that anyone would spend 20 minutes or more reading this monthly packet approaching 4000 words. Certainly, UM urology residents and faculty are too busy to give this more than a glance, and that’s OK by me. Of the 10 items usually offered I’d be happy if most folks just skimmed them and perhaps discovered one of enough interest to read in detail. Conversely, some alumni and friends hold me to account for each word and fact, and they are enough for me to know that this communication (What’s New email and Matula Thoughts website) is more than my whistling in the wind.

 

 

The_Doctor_Luke_Fildes copy

One.

Art & medicine. Luke Fildes’s painting, The Doctor, shown here last month, deserves further consideration in the afterglow of Don Nakayama’s Chang Lecture on Art & Medicine. [1892, Tate Gallery]. The duality of the doctor-patient relationship, ever so central to our profession, has gotten complicated by changes in technology, growth of subspecialties, necessity of teams and systems, and the sheer expense of modern healthcare. As Fildes shows, medical relationships in the pediatric world extend beyond twosomes and this actually pertains for all ages, since no one is an island. That nuance notwithstanding, the patient experience through the ages and into the complexity of today remains the central organizing principle of medicine.

Nakayama & Chang

[Dr. Chang & Don Nakayama]

An article in JAMA recently explored the patient experience via the Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) Survey. Delivered to random samples of newly discharged adult inpatients, the 32 items queried are measurements of patient experience that parlay into hospital quality comparisons and impact payments. [Tefera, Lehrman, Conway. Measurement of the patient experience. JAMA 315:2167, 2016]

It is unfortunate that health care systems and professional organizations hadn’t previously focused similar attention on patient experience and only now are compelled to investigate and improve it by the survey. We may chafe and groan at HCAHPS, but it reflects well on representational government working on behalf of its smallest and most important common denominator – individual people.

Everyone deserves a good experience when they need health care whether for childbirth, vaccination, otitis, UTI, injury, other ailments and disabilities, or the end of life. If for nothing more than “the golden rule” all of us in health care should constantly fine-tune our work to make patient care experiences uniformly excellent because, after all, we all become patients at points in life. The individual patient care experience is the essential deliverable of medicine and the epicenter of academic health care centers from the first day of medical school to the last day of practice, after which we all surely will become patients again.

 

 

Twitter invasion

Two.

Educating doctors. Last week’s White Coat Ceremony was the first day of medical school class for Michigan’s of 2020. Deans Rajesh Mangulkar and Steven Gay with their admissions team assembled this splendid 170th UMMS class. Unifying ceremonies are important cultural practices and this one is an exciting milestone for students and a pleasant occasion for the faculty who will be teaching the concepts, skills, and professionalism of medicine. Families in attendance held restless infants, took pictures, and applauded daughters and sons. A “doctor in the family,” for most of the audience, happens once in a blue moon, a rare circumstance of joy, and certainly evidence of success and luck in parenting. The attentive audience for the 172 new students entertained only rare social media diversions. Julian Wan represented our department on stage.

Dee at White Coat

Dee Fenner’s keynote talk resonated deeply. She described her career as a female pelvic surgeon and its impact on patients and on herself. Dee talked about the symbolism of the white coat and skewered today’s hype about “personalized medicine”, saying that medicine is always rightly personalized; our ability to tailor health care to the individual genome is just a matter of using better tools.  Alumni president (MCAS) Louito Edje said: “This medical school is the birthplace of experts. You have just taken the first step toward becoming one of those experts.” She recommended cultivation of three fundamental attitudes to knowledge: humility, adaptability, and generosity. Students then came to the stage and announced their names and origins before getting “cloaked.”

Cloaking

The ceremony passes quickly, but is long remembered. Students shortly immerse in intense learning, although medical school is kinder today with less grading, rare attrition, and greater attention to personal success and matters of team work.

New student

My favorite “new medical student story” concerns the late Horace Davenport. He had retired before I arrived in Ann Arbor, but remained active in the medical students’ Victor Vaughn Society that met monthly at a faculty home for a talk over dinner. Davenport, an international expert in physiology, was a superb and fearsome teacher as one student, Joseph J. Weiss (UMMS 1961), recalled from the fall of 1957.

“In our first physiology lecture Dr. Horace Davenport grabbed our attention by announcing that the first person to answer his question correctly would receive an ‘A’ in physiology and be exempt from any examinations or attendance. The question was: ‘What happened in 1623? The context implied an event of significant impact to human knowledge. After a long pause the amphitheater echoed with answers: the discovery of America, the landing of the pilgrim fathers, the death of Leonardo da Vinci. Then Nancy Zuzow called out: ‘The publication of William Harvey’s The Heart and its Circulation’. There was sudden silence. She must be right. How clever of her. Of course a physiologist would see this landmark publication as an event to which we should give homage. Who would have thought that Nancy was so smart? Even Dr. Davenport was impressed. He asked her to stand, and acknowledged that she had provided the first intelligent response. ‘However,’ he noted, ‘that publication occurred in 1628.’ No one could follow up up on Nancy’s response. Dr. Davenport looked around the room, sensed our ignorance, realized we had nothing more to offer, and then said: ‘1623 was the publication of Shakespeare’s First Folio.’ He announced that we would now move on and ‘return to our roles as attendants at the gas station of life”,’ and began his first in a series of three lectures on the ABC of Acid-Base Chemistry.” [Medicine at Michigan, Fall, 2000.  Weiss, a rheumatologist who practiced in Livonia, passed away in October 2015.  Zuzow died in 1964, while chief resident in OB GYN at St. Joseph Mercy, of a cerebral hemorrhage.]

First folio

 

 

Three.

New Perspectives. Visiting professors bring different perspectives and last month the Department of Urology initiated its new academic season with several superb visitors. Distinguished pediatric surgeon Don Nakayama gave our 10th annual Chang Lecture on Art and Medicine on the Diego Rivera Detroit Industry Murals. [Below: full house for Nakayama at Ford Auditorium]

Chang Lecture

I’ve been asked what relevance an art and medicine lecture has for a urology department’s faculty, residents, staff, alumni, and friends. Davenport would not have questioned the matter. This year, in particular, the lecture made perfect sense with Don’s discussion of what can now be called the orchiectomy panel in the Detroit Institute of Arts murals. Hundreds of thousands of people have viewed this work since 1933, including the surgical panel that art historians labeled “brain surgery” – a description unchallenged until Don revealed the scene represented an orchiectomy. His Chang Lecture explained the logic of Rivera’s choice.

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Grossmans

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[Top: Caleb & Sandy Nelson; Middle: Bart & Amy Grossman, Bottom: George Drach]

The day after the Chang Lecture, Caleb Nelson (Nesbit 2003) from Boston Children’s Hospital and Bart Grossman (Nesbit 1977) of MD Anderson Hospital in Houston delivered superb Duckett and Lapides Lectures. Caleb discussed the important NIH vesicoureteral reflux study while Bart brought us up to date on bladder cancer, greatly expanding my knowledge regarding the rapid advances in its pathogenesis and therapy. George Drach from the University of Pennsylvania provided a clear and instructive update on Medicaid coverage for children. Concurrent staff training went well thanks to those who stayed behind from this yearly academic morning to manage phones, clinics, and inevitable emergencies.

Lapides Lecture

[Above: Lapides Lecture, Danto Auditorium]

 

 

 

Tortise on post

Four.

Observation & reasoning. Don Coffey, legendary scientist and Johns Hopkins urology scholar, retired recently. Among his numerous memorable sayings he sometimes mentioned an old southern phrase: “if you see a turtle on a fencepost, it ain’t no coincidence.” A tortoise on a post isn’t some random situation that happens once in a blue moon, it is more likely the result of a purposeful and explainable action. (Of course, it is also not a nice thing.) Coffey was arguing for the importance of reflective and critical thinking as we stumble through the world and try to make sense of it, whether on a summertime pasture, in an art gallery, or in a laboratory examining Western blots.

[Above: tortoise sculpture on post. Mike Hommel’s yard AA, summer, 2016. Below: Coffey]

Coffey

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Richard Feynman (above), Nobel Laureate Physicist, offered a related metaphor.

“What do we mean by ‘understanding’ something? We can imagine that this complicated array of moving things which constitutes ‘the world’ is something like a great chess game being played by the gods, and we are observers of the game. We do not know what the rules of the game are; all we are allowed to do is to watch the playing. Of course if we watch long enough we may eventually catch on to a few of the rules… (Every once in a while something like castling is going on that we still do not understand).” [RP Feynman. Six Easy Pieces. 1995 Addison-Wesley. P.24]

Observation, reasoning, and experimentation are the fundamental parts of the scientific method that allows us to figure things out. Feynman’s castling allusion is brilliant.

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[EO Wilson at UM LSI Convocation 2004]

E.O. Wilson went further with his thoughts on consilience, the unity of knowledge.

“You will see at once why I believe that the Enlightenment thinkers of the seventeenth and eighteenth centuries got it mostly right the first time. The assumptions they made of a lawful material world, the intrinsic unity of knowledge, and the potential of indefinite human progress are the ones we still take most readily into our hearts, suffer without, and find maximally rewarding through intellectual advance. The greatest enterprise of the mind has always been and always will be the attempted linkage of the sciences and humanities. The ongoing fragmentation of knowledge and resulting chaos in philosophy are not reflections of the real world, but artifacts of scholarship. The propositions of the original Enlightenment are increasing favored by objective evidence, especially from the natural sciences.” [Wilson. Consilience. P. 8. 1998]

 

 

superheroes

Five.

Superheros. Somewhat to our cultural disadvantage our brains are hardwired to favor physical performance, entertainment, and appearances over intellectual leaps of greatness. We celebrate actors, athletes, politicians, musicians, and cartoons far more than great intellects. Worse, intellectuals in many periods of history were deliberately purged.

Coffey, Feynman, and Wilson are real superheroes of our time. Their ideas have been hugely consequential and they individually are role models of character and intellect. Another name to add to the superhero list is Tu Youyou (屠呦呦). My friend Marston Linehan first alerted me to her incredible story and discovery of artemisinin. It is also a story of how the better nature of humanity is subject to the dark side of our species and the nations we let govern us.

Born in Ningbo, Zhejiang, China in 1930 Tu Youyou attended Peking University Medical School, developed an interest in pharmacology, and after graduation in 1955 began research at the Academy of Traditional Chinese Medicine in Beijing. This was a tricky time to be a scientist in Maoist China. Ruling authorities favored peasants as the essential revolutionary class and in May 1966, the Cultural Revolution launched violent class struggle with persecution of the “bourgeois and revisionist” elements. The Nine Black Categories (landlords, rich farmers, anti-revolutionaries, malcontents, right-wingers, traitors, spies, presumed capitalists, and intellectuals) were cruelly relocated to work or forage in the countryside while neo-revolutionaries disestablished the national status quo.

In 1967 as North Vietnamese troops contended in jungle combat with US forces, chloroquine-resistant malaria was taking a heavy toll on both sides. Mao Zedong launched a secret drug discovery project, Project 523, that Tu Youyou joined while her husband, a metallurgical engineer, was banished to the countryside and their daughter was placed in a Beijing nursery. Screening traditional Chinese herbs for anti-plasmodial effects Tu found Artemisia (sweet wormwood or quinghao) mentioned in a text 1,600 years old, called Emergency Prescriptions Kept Up One’s Sleeve (in translation). She led a team that developed an artemisinin-based drug combination, publishing the work anonymously in 1977, the year after the revolution had largely wound down and only in 1981 personally presented the work to World Health Organization (WHO). Artemisinin regimens are listed in the WHO catalog of “Essential Medicines.” Tu won the 2011 Lasker-DeBakey Clinical Medical Research Award and in 2015 the Nobel Prize In Physiology or Medicine for this work.

Artemisia

[Above: Artemisia annua. Below: Tu Youyou with teacher Lou Zhicen in 1951]

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Six.

It may be a human conceit to think of ourselves as the singular species on Earth capable of self-improvement. Considering the impact of Coffey, Feynman, Wilson, and Tu among other intellectual superheroes, imagination at their levels seems a rarity in the universe. Yet, any sentient creature wants to improve its comfort as well as its immediate and future prospects, for who is to say that a whale, a dolphin, a gorilla, or an elephant cannot somehow imagine a more comfortable, happier, or otherwise better tomorrow? In anticipation of another day, birds make nests, ants make tunnels, and bees make hives.

We humans have extraordinary powers of language, skill (with our cherished opposable thumbs), and imagination that provide unprecedented capacity to improve ourselves. Accordingly we easily imagine ourselves in better situations, whether physically, materially, intellectually, or morally, and as it is said, if we can imagine something we probably can create it.

Imagination of a better tomorrow is part of the drive for change as we consider our political future, although this can be risky. The intoxicating saying out with the old and in with the new has led to such things as the United States of America in 1776 or the Maastricht Treaty and European Union in 1992. Change, however, does not always produce happy alternatives, as evidenced by the Third Reich, the dissolution of Yugoslavia, the Arab Spring, or Venezuela’s Chavez era. Disestablishment does not predictably improve life for most people. The human construct, at its best and most creative, rests on a fragile establishment of geopolitical, economic, and environmental stability. The status quo that has been established may be imperfect, but is disestablished only at considerable risk.

Representational government and cosmopolitan society seem to be the best-case scenario for what might be called the human experiment wherein various factions of a diverse population come together to create a just social agenda and build a better tomorrow. The threat to this utopian scenario comes from factionalisms and tribalisms that insert narrow self -interests and litmus tests for cooperation into any consensus for agenda. We see this in the mid-east, in the European Zone, and in American presidential election cycles. Generally ignored or forgotten by competing factions and litmus-testers is the worst-case scenario of civil collapse. We experienced limited episodes of this in two World Wars, southeastern Asian catastrophes, central African genocides, Yugoslavia’s dissolution, and the collapse of Syria to name some instances. However sturdy we think human civilization may be, it is only a thin veneer in a random and dangerous universe. Civil implosions of one sort or another occur intermittently in complex societies, however we must become better at predicting them, circumventing them, and most importantly preventing their dissemination. Their catastrophic nature surpasses any sectarian interests or individual beliefs beyond the survival of civilization itself.

 

 

Moon June 17, 2016

Seven.

The Blue Moon, mentioned earlier, is a picturesque metaphor for an uncommon event. It’s actually not random, inasmuch as a blue moon is a second full moon in a given month (or other calendar period), so the next one can be accurately predicted. Since a full moon occurs about every 29.5 days, on the uncommon occasions it appears at the very beginning of a month, there is a chance of Blue Moon within that same month. The next Blue Moon we can expect will be January 31, 2018.

The song is a familiar one. It was originally “MGM song #225 Prayer (Oh Lord Make Me a Movie Star)” by Richard Rogers and Lorenz Hart in 1933. Other lyrics were applied, but none stuck until Hart wrote Blue Moon in 1935.

Nothing is visually different between blue moons or any other full moons. I took this picture (above) of a nearly full moon this June after some trial and error. A full moon is a beautiful thing and can’t help but give anyone a sense of the small individual human context. Friend and colleague Philip Ransley, now working mainly in Pakistan, spent much of his career aligning his visiting professorships around the world with lunar eclipses and lugging telescopes and cameras along with his pediatric urology slides. Receiving the Pediatric Urology Medal in 2001, barely a month after the tragic event of September 11, 2001, he spoke on lunar-solar rhythms, shadows, and their relationship to the human narrative: “… I would like to lead you into my other life, a life dominated by gravity and its sales rep, time. It has been brought home to us very forcibly how gravity rules our lives and how it governs everything that moves in the universe.” [Ransley. Chasing the moon’s shadow J. Urol. 168:1671, 2002]

PGR2

[PG Ransley c. 2005]

Ransley is currently working in Karachi, Pakistan at the Sindh Institute of Urology and Transplantation, the largest center of urology, nephrology, and renal transplantation in SE Asia. The pediatric urology unit at SIUT is named The Philip G. Ransley Department. [Sultan, S. Front. Pediatr. 2:88, 2014]

 

 

Eight.

Ruthless foragers. Earlier this summer a friend and colleague from Boston Children’s Hospital, David Diamond, brought me along for a bluefish excursion off of Cape Cod. These formidable eating machines travel up and down the Atlantic coast foraging for smaller fish. Like many other targets of human consumption, blue fish are not as plentiful as they once were, although they are hardly endangered today.

BluefishBiomass_Sept2015

[From Atlantic States Marine Fisheries Commission]

Just as we label ourselves Homo sapiens, the bluefish are Pomatomus saltatrix. Both, coincidentally, were named by Linnaeus, the botanist who got his start as a proto-urologist, treating venereal disease in mid 18th century Stockholm. His binomial classification system (Genus, species) is the basis of zoological conversation, although genomic reclassification will upend many assumptions. Also like us, the bluefish is the only extant species of its genus – Pomatomidae for the fish and Hominidae for us. Thus we are both either the end of a biologic family line or the beginning of something new. Our fellow hominids, such as Neanderthals, Denisovans, or Homo floresiensis didn’t last much beyond 30,000 years ago, although they left some of their DNA with us. It may be a long shot, but I hope H. sapiens can go another 30,000 years.

Bluefish

[Bove: ruthless foragers]

Teeth

Like us, Pomatomus saltatrix are ruthless foragers, eating voraciously well past the point of hunger. Their teeth are hard and sharp, reminding me of the piranha I caught on an unexpected visit to the Hato Piñero Jungle when attending a neurogenic bladder meeting in Venezuela some 20 years ago. Lest you think me a serious fisherman, I disclose there’ve not been many fish in between these two.

Pirhana

[one of 4 piranha geni (Pristobrycon, Pygocentrus, Pygopristis, & Serrasalmus that include over 60 species]

Linnaeus gave bluefish a scientific name in 1754, describing the scar-like line on the gill cover and feeding frenzy behavior (tomos for cut and poma for cover; saltatrix for jumper, as in somersault). I learned this from the book Blues, by author John Hersey (1914-1993), who was better known for his Pulitzer novel, A Bell for Adano (1944) or his other nonfiction book, Hiroshima (1946). [Below: Hersey]

Johnhersey

Michigan trivia: Hersey lettered in football at Yale where he was coached by UM alumnus Gerald Ford who was an assistant coach in football and boxing for several years before admission to Yale’s law school. Hersey became a journalist after college and graduate school in Cambridge. In the winter of 1945-46 while in Japan reporting for The New Yorker on the reconstruction after the war he met a Jesuit missionary who survived the Hiroshima bomb, and through him and other survivors put together an unforgettable narrative of the event. The bluefish story came later (1987).

 

 

Nine.

Today & tomorrow. Today is the start of the Summer Olympics in Rio de Janeiro, Brazil where 500,000 visitors are expected, presumably well covered and armed with insect repellent due to fears of Zika, an arbovirus related to dengue, yellow fever, Japanese encephalitis, and West Nile viruses.
Tomorrow is a sobering anniversary. I was 11 days old, on August 6, 1945, when, at 8:15 AM, a burst of energy 600 meters above the Aioi Bridge in Hiroshima, Japan incinerated half the city’s population of 340,000 people. Don Nakayama wrote a compelling article on the surgeons of Hiroshima at Ground Zero, detailing individual stories of professional heroism. [D. Nakayama. Surgeons at Ground Zero of the Atomic Age. J. Surg. Ed. 71:444, 2014] We reflect on Hiroshima (and Nagasaki) not only to honor the fallen innocents and to re-learn the terrible consequences of armed conflict, but also to recognize how close we are to self-extermination. A new book by former Secretary of Defense, William Perry, makes this possibility very clear, showing how much closer we came to that brink during the Cuban Missile Crisis. [Perry. My Journey at the Nuclear Brink. Stanford University Press. 2016]

 

 

Ten.

Self-determination vs. self-termination. Life, and our species in particular, is far less common in the known universe than Blue Moons, it might be said, although those moons actually are mere artifacts of calendars and imagination. Art and medicine are distinguishing features of our species, Homo sapiens 1.0. The ancient cave dwelling illustrations of handprints on the walls and galloping horses, are evidence of our primeval need to express ourselves by making images. The need to care for each other (“medicine” is not quite the right word) is an extension from the fact that we are perhaps the only species that needs direct physical assistance to deliver our progeny. If our species is to have a future version (Homo sapiens 2.0) we will have to check ourselves pretty quickly before we terminate ourselves, through war and genocide, consumption of planetary resources, or degradation of the environment. While representational government, nationally and internationally, may be our best hope to prevent termination we will have to represent ourselves a lot better. That’s a fact whether here in Ann Arbor, in Washington DC, in China, Africa, Asia, or Europe.

Tribalism resonates with many deep human needs and it has gotten our species along this far, but H. sapiens 2.0 will have to make the jump from tribalist behavior to global cosmopolitanism. Sebastian Junger, a well-known war journalist, has written a compelling book that explores the human need for a sense of community that he describes by the title, Tribe. While we need better sense of community in complex cosmopolitan society, we cannot accept primitive tribalism, sectarianism, or nativism of exclusivity that exacerbate conflict among the “isms.” Tribalism cannot create an optimal or even a good human future whether the version is Brexist or ISIS, paths retrograde to human progress and the wellbeing of humanity in general.

Girl with pearl

[Girl with Pearl Earing, Vermeer, c. 1665, & viewers at Mauritius Museum, The Hague]

Reflections on art and medicine lead to cosmopolitan and humanitarian thought and behavior. Humanistic reflection, shared broadly, should track us more closely to a utopian scenario, rather than to catastrophe that is only a random contingency away.

Tulp

[Anatomy Lesson of Nicolaes Tulp. Rembrandt, 1632. Mauritius Museum, The Hague]

 

Thank you for reading our Matula Thoughts.

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

Commencement 2016

DAB What’s New –July 1, 2016

Matula_Logo1

3805 words

 Birthing Couple_16681983_5x5-150dpi

One.  

Like the matula, this African birthing figure is a rich symbol for the healing arts, or “medicine”, if you apply that term as a generality. We hominids, unlike most other creatures, need some help with delivery of babies. Usually, birthing assistants offer emotional support and necessary physical aid while nature takes its course, but sometimes the midwife or physician will be life-saving. Birth assistance, as depicted above, has been going on since the dawn of mankind; each generation teaches its successors how best to do the job, based on experience, knowledge, and the technology available. [Figure: JAMA cover and St. Louis Art Museum. Birthing Couple. C. 1200. Niger Delta]

            Another cycle of teaching the next generation begins today in Ann Arbor as medical students transition into house officers, new fellows morph into subspecialists, and new faculty begin careers as urologists, educators, and leaders. Incoming residents feel a sense of life’s infinite potential, yet their careers will pass by in the blink of time’s eye. These thoughts came to mind as I reflected on the recent loss of Carl Van Appledorn and paused by his residency class picture of 1972.

Van Appeldorn 1972

[Front: 2nd from left Ananias Diokno, Ed Tank 3rd from left, John Konnak 4th, Jack Lapides 5th; top row – Bill Hyndman 4th from L, Carl 7th, Dan Karsch 8th, Lee Underwood 9th, Sherman Silber far right]

My residency training began in 1971 at UCLA and the surgery department picture hangs on my office wall [below]. One of my former senior residents, Jim Skow, still practices thoracic surgery in California, but I think most others senior to me then have hung up their stethoscopes. One chief resident, Mike McArthur, retired to run The Caldwell Family Zoo in Tyler, Texas. A number of my fellow interns are still working: Erick Albert (urologist in Lodi, California), Arnie Brody (hand surgeon in Pittsburgh), Ron Busuttil (Chair of Surgery at UCLA), David Confer (urologist in Tulsa, OK), John Cook (general and vascular surgeon in Billings, Montana), Jon Kaswick (urologist at Kaiser in LA), Doug McConnell (recently retired from cardiothoracic surgery in Long Beach and Redding, CA), Edward Lewis Clark Pritchett III (cardiologist at Duke), and Eric Zimmerman (neurosurgeon in Traverse City). I have lost track of most of the others (we started with 18 surgery interns and ended with 5 chiefs).

DAB 1971

A few faculty who taught me at UCLA are still working. I saw Bob Smith at the AUA last month, Rick Ehrlich maintains simultaneous extraordinary careers in urology as well as photography, and Shlomo Raz is quite busy at UCLA.

DAB, RBS  

[Above: DAB & Bob Smith; below Rick at AAP 2010]

RME

            When I finished training, board certification lasted a lifetime, hospital credentialing was rudimentary, and one’s frame of reference as a physician was largely centered on individual performance, skills, and drive. Relationships to larger systems, while important and necessary, were secondary concerns. Since then the dynamic has reversed and large systems such as the electronic medical record, peer review, MOC, RVUs, and checklists dominate individuals. Credentialing, provider enrollment, and billing have become complex and require substantial infrastructures. Proposed MACRA regulations, replacing the Sustainable Growth Rate method of physician reimbursement and published last April, prescribe financial penalties for single and small (2-9 practitioner) medical practices. The end is probably in sight for the traditional duality of health care with one patient and one provider at a time. For better and for worse, teams and systems are replacing individuals.

 

 

Two.

Five UM chief residents and four fellows graduated from our training program last month and we celebrated over dinner at the Art Museum to honor them and their families. Rebekah Beach, Miriam Hadj-Moussa, Michael Kozminski, Amy Li, and Galaxy Shah, plus Abdul Al Ruwaily, Sapan Ambani, Chad Ellimoottil, and Yahir Santiago-Lastra completed residency and fellowships. Their next career steps disperse them to Seattle, Phoenix, Grand Rapids, Duluth, Saudi Arabia, San Diego, and Ann Arbor. Below, 4 chiefs honor our reconstructive urology faculty member Bahaa Malaeb with the Silver Cystoscope Award.

Chiefs 2016

As these trainees leave, a new cycle of health care education begins in Ann Arbor and the UM Health System enters its first fiscal year under a new organizational model. To understand this change, a little history is helpful.      The University of Michigan began in 1817 in Detroit and moved to Ann Arbor in 1837, but didn’t establish a medical school until 1850. Back then, doctors were educated by two years of lectures and anatomy dissection. They studied ancient and fairly static topics, but change was in the air as the modern conceptual basis of medicine was on the verge of consolidation. Germ theory, pathology, biochemistry, physiology, and anesthesiology were joining the conversation of health care. Medical schools became places not just for lectures and anatomy dissection, but places with laboratories for the study of human biology and disease, as well as surgery.

Med School Bldg

[Above: Medical School; below: faculty house/first hospital]

Ist hosp

In 1867, a UM faculty house was converted into a dormitory for patients undergoing surgery in the medical school, making the University of Michigan the first university to own and operate a hospital. The medical school curriculum grew in complexity and length to 4 years, adding “basic science” laboratories and the “clinical laboratories” of bedside instruction. The hospital necessarily enlarged in scale, functions, personnel, and equipment.  By the late 19th century, some medical student graduates began to spend a year or more in the hospital and medical school learning new skills and fields of practice.

 

 

Three.          

            The UM AMC. By 1910, when the Flexner report reformed medical education, budgets of UM hospital ($70,000/year) and medical school ($83,000/year) were comparable. Management of the two organizations diverged increasingly in the 20th century, requiring different sets of expertise. Hospital management followed the business model of American industry, centered on the principles of managerial accounting with cost centers, unit margins, accrual accounting, capital allocation, etc. Medical school management more closely followed academic principles of not-for-profit organizations with budgets decentralized to academic units that had their own goals and measures of success.

Cabot copy

Hugh Cabot, world renowned urologist, arrived from Boston in late 1919, attracted by the full-time salary model and opportunity to build a multi-specialty surgery department in Ann Arbor. He became medical school dean in 1921 and by 1926 opened a modern hospital of 1000 beds with specialties that defined the states-of-the art in medicine and surgery. That year Cabot’s first trainees, Charles Huggins and Reed Nesbit, began postgraduate medical education. Cabot’s confrontational personality produced significant backlash as he built his medical mecca, an integrated group practice. He was abrasive and blind to the value of diversity, either in opinions that differed from his own or in people themselves. Regional physicians disliked him and ultimately the regents fired him, “in the interests of greater harmony”, on February 11, 1930.

Hosp 26

Without a dean, the Medical School was run by its Executive Committee for 3 years, and a third financial enterprise became important in addition to hospital and medical school systems. This was the business of professional services. Senior professors then could independently bill for their professional services through their own offices and other employees were paid by those professors or the hospital. The lines between medical school, hospital, and professional offices regarding “who paid for what” were contested.

            It was natural for the hospital to provide outpatient services and in 1953 it opened a new building for the 24 departmentally-based ambulatory clinics (this is now the Med Inn Building) that quickly saw 20,000 patients monthly. While hospitals share many similarities with ambulatory care facilities, the work flows and challenges are actually quite different. Dissatisfaction grew over the next 50 years as physicians found themselves marginalized in the systemic clinical decision-making as medical care became increasingly complex, specialized, and expensive. Accounting methodologies for hospital and medical school differed. Matt Comstock, our Senior Finance Executive, explains it well:The entire university follows GASB (government accounting standards) when filing financial reports.  But the units within the University have had differences in how accounting standards were (and still are) applied internally to “run the business.”  The hospital followed more traditional accrual accounting standards that line up with GASB for external reporting. The UMMS used a  “sources/uses” view (think cash) for many years.” As hospital directors managed the space, capital allocations, and personnel for the departmentally-based outpatient clinics, tensions grew between hospital managerial accountancy and departmental/faculty academic missions.

Another factor arose in the latter half of the 20th century when academic medical centers made NIH funding a priority in the academic mission and failed to recognize that their essential deliverable needed to be patient care. This is the moral epicenter of academic medicine. When done right, it drives the rest of the mission and creates a healthy financial margin. Our motto in the Urology Department has become kind and excellent patient-centered care, thoroughly integrated with education and innovation at all levels. This cannot be accomplished by the providers alone, it requires an integrated systemic effort in this era of complex, team-based health care. An archipelago of cost centers cannot accomplish this task. As Toyota’s Lean Process Systems have taught western business – productivity, efficiency, and workplace satisfaction are maximized when key stakeholders participate in decisions about their work. In other words, process improvement is best accomplished by the people executing the processes.

 

 

Four.

            Archipelagos of costs centers. This metaphor comes from my friend Doug McConnell who stopped in AA with his wife Bonny on their retirement tour. We recounted similar experiences in health systems, such as seeing patients on hold in operating rooms after surgery was completed, because the recovery room was full due to nursing staff shortages in an ICU. The costs of an idle staffed OR far outweigh any saved ICU nursing position. Delay or cancellation of subsequent patients adds to cost and frustration. Downstream effects from one “efficient” cost center can sabotage an entire hospital.

Although ambulatory care activities led the way for UMHS restructuring, we still have much to gain in terms of better management of our entire enterprise in a patient-centric fashion. Just as Ford, Chrysler, and GM learned, managerial control by accounting (the archipelago of cost centers managed by regulation of supply and demand) is a failed experiment of western business, and lean process systems as developed by Toyota produces better products, with greater efficiency, and greater satisfaction for all customers.

            In 2007, UM hospital transferred ambulatory care operations to the clinical faculty, organized in the form of a Faculty Group Practice (FGP). Led by dean Jim Woolliscroft and associate dean for clinical affairs David Spahlinger, it consisted of the clinical chairs and elected positions from 5 clinical cohorts. With a book of business of 0.8 billion dollars, it was a risky venture, as the FGP assumed all of the downside risk, half the upside risk (the other half to split with the hospital), and no capital dollars. Ambulatory activities were split into 90 ambulatory care units (ACUs) functioning under the principle of keeping local decisions as close to “where the work is done” as possible.

Before merger of Medical School and Hospital Finance Offices in 2009, the two offices were not only competitive, but in the 1990s were so suspicious of each other that their staffs were prohibited from sharing information. This situation was reflective of systemic dysfunction related to structure, governance, and personality conditions that incented competitive silos. The merger brought Medical School financial reporting to the more traditional accrual view of the world, but also brought clinical and academic values to the processes, personnel, and capital of health care business.

Further changes this year aim to create a more integrated organization with a balanced mission of education, clinical practice, and research, but centered on an essential deliverable of kind and excellent patient care. Entering FY 2017, we have 150 ACUs and are applying our operational ACU principles throughout the larger UM Health System.

 

 

Five.

UM AHC reorganization. On January 1, 2016 our EVPMA, Marschall Runge, incorporated the title and functions of Medical School Dean in his office. The new organizational chart under him features 3 senior associate deans: 1.) clinical senior associate dean & president of the UMHS, David Spahlinger; 2.) academic senior associate dean, Carol Bradford, effective July 1; and 3.) scientific senior associate dean, TBD.

            The UMHS under David Spahlinger as its president features 3 operational units: a.) the UM Medical Group (UMMG, formerly the FGP); b.) Hospital Group I (UM Main Hospital and the CVC); and Hospital Group II (Mott & Women’s Hospital). Each hospital group will be managed under a leadership triad consisting of physician, nursing, and administrative leaders with a committee representing key stakeholders, namely “the people who do the work.”  The pieces of this new matrix are still coming into position – it is a work in progress, but the immediate challenges are:

a.)           Maximizing the patient experience and minimizing waste in clinical operations while enhancing the trifold academic mission.

b.)           Consolidation of large health systems around UMHS. Our educational programs (800 medical students & Ph.D. candidates, 1100 residents & fellows in 100 different areas of focused clinical practice, plus many other health education learning groups) require 400,000 covered lives locally and at least 3.5 million lives regionally.

c.)           Changing health care laws and regulations that force reimbursement away from individual professional payments to alternative methods such as bundled payments, episode of care payments, payments (or penalties) based on notions of value and quality (still incompletely defined or understood).

Accordingly, we need urgent investment to increase the scale and work-flow of our clinical operations.

 

 

Six.

            A new season begins. Today, July 1, our new residents and fellows enter into this mix of change. The new residents (“interns”) are called PGY 1s (postgraduate year ones) as they enter the career-defining stage of medical education, a time that exceeds the years spent in medical school. New house officers & fellows are in search of competency. Our job as faculty, along with senior residents and fellows, is to help them acquire the skills, professionalism, and hunger for excellence that will distinguish them as our colleagues and successors. It is a tall order and while they seek professional competency during residency, attainment of mastery will be a lifelong pursuit.

            Daniel Pink, in his book Drive, claims that humans need autonomy, mastery, and purpose if they are to achieve success and fulfillment in life. Purpose is readily found in most health care careers. Autonomy, while necessarily threatened by the larger systems and regulations, is still found in medicine. Mastery of a skill, or task, it is said, requires around 10,000 hours of practice. Urology, however, is more than a single skill, and judging empirically from the length of residency and fellowship training, it is easy to extrapolate that the hours necessary for mastery of urology exceeds 30,000. 

            Our profession, however, is the practice of medicine – a continuous process – so self-education is never done. Hunger for excellence drives  good doctors who continue to learn, on a daily basis from patients, from colleagues, and from experiences that fuel curiosity. Drive for excellence is a part of the professionalism that society expects from its physicians and other health care workers.

 

 

Seven.          

Summer art fair.  I had lived in Ann Arbor for 10 years before attending an Art Fair and thus deliberately began our Duckett Lecture in Pediatric Urology as the first educational event of each new fiscal/academic year on Friday of the Art Fair. We hold simultaneous staff training for the non-physicians of our department and then give the afternoon free to everyone (except for a skeleton crew to staff the phones, consults, urgencies) as a time to visit the Art Fairs or stay home and “reboot” for the new academic year. It is costly to drop a business day from our books, but we justified this as both an education/training morning and a yearly “afternoon off” birthday gift for our employees. This year (Friday July 22) the Duckett lecturer will be Caleb Nelson (Nesbit 2004), faculty member at Harvard and the Boston Children’s Hospital.

Caleb

[Above: Caleb Nelson. Below: Bart Grossman]

Bart 2016

In 2006 we added the Lapides Lecture to broaden the scope of the morning, and this year it will be Bart Grossman (Nesbit 1997), our former Urology Section Chief (2003-2004), currently professor at MD Anderson Hospital in Houston.

Building on the art fair theme, we added the Chang Lecture on Art & Medicine in 2007 to kick off the academic events. This year, Don Nakayama, a distinguished pediatric surgeon, will be speaking about his novel discovery in the Diego Rivera murals at the Detroit Institute of Arts. This will be on Thursday at 5 PM July 21 in Ford Amphitheater University Hospital.

Nakayama

Don Nakayama

 

 

Eight.            

Professions & commodities. Society recognizes a difference between a profession such as medical practice, and a commodity such as pork bellies. The principle value of a commodity is the commodity itself, assumed (although not always accurately) to be of a standard quality. The value of a professional service, while assumed by its status as professional to be of an acceptable standard, is more nuanced. While an acceptable standard is expected, society anticipates a higher level of duty and service than from a commodity and accordingly society allows professions to set their standards and train their successors. Professions are constantly evolving as science, practice, and technology provide new tools and new challenges. Society also shapes new expectations and demands. A pork belly, for the most part, will always be a pork belly whether you hold one in your hands today or imagine one in 50 years. Care of today’s patient with bladder cancer will be very different from that of a patient in another half century. The stories of today’s pork bellies will not be closely intertwined with the commodity 50 years hence. The same is not so true as with treatment of bladder cancer, which will be built upon many stories of discovery, trial, failure, and tragedy going forward.

 

 

Nine.

Lasker. One way to understand the practice and science of medicine today, and to anticipate the opportunities and needs of tomorrow, is through stories of discovery. These are represented (although incompletely) in major recognitions such as the Nobel Prize or Lasker Awards and deserve more attention in our cultural literacy, so I like to highlight them from time to time. The Lasker program turned 70 years old last year and its Basic Medical Research Award went to Evelyn Witkin, for work demonstrating responses of bacteria to DNA damage and to Stephen Elledge for showing the molecular mechanisms by which eukaryotic cells recognize and respond to DNA damage. The Lasker-DeBakey Clinical Medical Research Award went to James Allison for enabling T-cells to attack cancer cells by removing “checkpoints” on these “bad guys” that normally inhibit the T-cells. Notice DeBakey’s name enjoined to the Lasker clinical award (DeBakey was mentioned in May’s What’s New/Matula Thoughts). The work celebrated in last year’s Laskers will no doubt influence urology, among other fields, in years to come. Allison’s immunotherapy work has already profoundly changed the face of melanoma management. [Pomeroy. The Lasker Awards at 70. JAMA. 314: 1117, 2015]

            If you go to the Lasker Foundation web page you can find the Essay Contest with three superb essays in 2016 by a Ph.D. student (David Ottenheimer at Johns Hopkins on modern neuroscience tools for psychiatric illness), a second year medical student (Therese Korndorf at U. Illinois Peoria on the bacterial social network and quorum sensing), and a pediatrics resident at LA Children’s (Unikora Yang on DNA editing with CRISPR). This is open to medical students, residents, graduate students, and postdocs. First prize yields $10,000. Maybe one of our learners will get inspired to write a 2017 essay.

 

 

Ten.

            Commencement. The first day of medical school is offset for a month after the interns and older residents began their cycle. The White Coat Ceremony marks the start of our next 4-year medical school curriculum when students and families assemble at Hill Auditorium Saturday 10 AM July 30. New students will walk across the stage, announce their names and schools of origin, and receive white coats from the Medical School, pins from the Alumni Society, and stethoscopes provided by clinical faculty and several donors. The short white coats, symbols of medical student education, will be traded for the longer white coats of residents and faculty 4 years from now. The White Coat Ceremony, open to the public, is a lovely occasion to reconnect with our purpose of medical education. It would be a shame for a Michigan faculty member to miss the chance to do this at least once in a career.

The stethoscope inclusion began 15 years ago under Allen Lichter’s deanship, believing that the white coat and pin needed more symbolic weight to match the moment. The stethoscope is today’s “badge of office” for physicians and it’s certainly a substantial gift – the high quality ones we give out cost over $225 each. Stethoscopes connect us to patients and are a fitting metaphor for listening to the patient, in a larger sense than hearing heartbeats. Before the stethoscope was invented (by Laennec in Paris in 1816) the symbol for medical practice was the matula – the glass flask used by doctors to examine urine. This device, evident in paintings and sculptures, was a perfect metaphor for observation: the clinician’s “gaze”. More practically, the matula was the tool of uroscopy.

            The African nativity scene, the uroscopy matula, and now the stethoscope are symbols of the practice of medicine, each reflecting progressive implementation of technology and each reflecting the human skills of comforting, observing, and reflective listening. Economic, social, and regulatory pressures on healthcare professions, medicine in particular, seem to be increasing and are  “commoditizing” services that human culture has, until now, largely left to the realm of the professions. Admittedly, many medical services can be readily commoditized, such as immunizations, screening physical exams, dental hygiene, and podiatry. These are important tasks that all people need and require training and skill, but can be delivered as standard practices. Expertise deploys along a bell-shaped curve of quality, but these can be efficiently standardized by algorithms and check-lists.

            Other medical services such as managing patients with UTIs, hypospadias, neurogenic bladder, stress incontinence, medullary sponge kidney, or prostate cancer involve more than simple checklists or single skill-sets. Even “episode-of-care” approaches will fail to capture the holistic approach that patients need for specific complaints, in the complex context of their comorbidities, families, and lifelong needs and aspirations.

            The Luke Fildes painting of 1891 represents the professional side of medicine better than most images. The artist’s first son, Philip, died of TB in 1877 and the doctor at the bedside inspired this great painting. A later son, Paul, would become an eminent physician with a complex career that encompassed roles both in the discovery of sulphonamide action and the alleged use of Botulin toxin to assassinate top Nazi Reinhard Heydrich in 1942. The toxin story, probably fanciful, doesn’t diminish the richness of the father’s metaphor for the profession of medicine. In fact, the tale expands any related dialogue to an unexpected dimension. Consider dropping in at Hill Auditorium in 4 weeks for our Medical School Commencement (Saturday, this year at 10 AM) and starting conversations with your professional successors as they initiate their journeys.

The_Doctor_Luke_Fildes copy

  

Thanks for reading What’s New and Matula Thoughts.

 

David A. Bloom