Matula Thoughts May 6, 2016

DAB What’s New May 6, 2016

Matula Thoughts Logo2

(3948 words)



Carl Van Appledorn, friend, Nesbit alumnus, and colleague, passed away last week. Carl trained under Jack Lapides and fulfilled an illustrious career as a superb urologist and beloved physician at St. Joseph Mercy Hospital. He spent a mini sabbatical in pediatric urology in Cambridge, England working with Bob Whitaker and when I came to Ann Arbor, Carl welcomed me most generously although I was “the competition.” We talked periodically about patients and I admired his work and gracious manner. As a University of Michigan and Nesbit alumnus, he supported his alma mater to the hilt. Later in his career Carl and his wife Sue developed an interest in international health for the underserved and they focused their attention in Ghana. Among other efforts, they facilitated care for a youngster with bladder exstrophy whom they brought to Ann Arbor and Mott Children’s Hospital with his mom for reconstructive surgery by John Park. The Van Appledorns generously created an endowment between the departments of Urology and OB/GYN for clinical and educational links to Ghana and the program is ongoing and growing. Carl’s passing is sad news indeed, but his name will carry on with his global program.



One.           May, at last.

May 2015

Ann Arbor and the University of Michigan Campus are especially lovely just now (shown above from the west side of the Cardiovascular Center last year). Cold days and wintry mixes are over and we are primed for spring. May brings, among other things, academic commencements, watershed moments when change is in the air. Last month in this column we referred to a commencement address by President John F. Kennedy at American University in 1963, for its relevance to environmental stewardship.
With Cuba “back” in the news recently, Kennedy’s speech is also relevant at a geopolitical level. In the aftermath of the Cuban Missile Crisis of October, 1962, when a showdown with the Soviet Union took us very close to the brink of nuclear war, Kennedy knew that world security was precariously dependent on constructive dialogue with our adversaries and his commencement address, called Strategy for Peace, helped turn the tide of the escalating confrontation and ushered in an improved era of diplomacy. A cautionary phrase from the speech is worth repeating again this month: “For in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s futures. And we are all mortal.”                             Thanks to the Internet, you can scour the world for notable commencement speeches, that while typically forgotten in the momentary excitement of most graduates and families, are retained the collective human memory of newspapers, libraries, and YouTube clips. An NPR web site ( lists 354 of The Best Commencement Speeches, Ever.



Two.           Significant speeches.
Even when unconnected to graduations, speeches may open opportunity for commencement of a new idea, if an audience picks up on it.
Around this time of year in 1850, May 15 to be exact, a young physician Ignaz Semmelweis gave a talk to the Imperial Viennese Society of Physicians urging physicians at Vienna General Hospital to clean their hands when they went to the delivery room. Animal experiments and clinical observation, coupled with a mentor’s death after an autopsy wound in 1847, convinced him that childbed fever was due to contaminating agents. His clinical experiment showed that the simple act of hand rinsing in chlorine markedly decreased the high incidence and fatality of childbirth sepsis in his hospital. While not a commencement speech, his talk might have commenced a new era in health care, but few in Semmelweis’s audience accepted the idea. (Our colleague at Michigan and current editor of Milbank Quarterly, Howard Markel, presented a discussion of this on PBS News Hour last year and John Park recently referred to it in his Mott Children’s Hospital blog.)
The same opportunity had been missed seven years before the Semmelweis speech when Oliver Wendell Holmes advanced the contagiousness concept at an evening scientific meeting of the Boston Society for Medical Improvement, yet the idea gained no traction. In 1867 Joseph Lister working in Glasgow wrote 2 papers in The Lancet that conclusively showed how antiseptic techniques converted the universal fatality of open fractures into probable survival, yet colleagues again failed to accept the idea. Listerian antiseptic methods were first only appreciated by German physicians and the idea diffused slowly back to England and the rest of the world over the next 20-30 years. Even today, we could do a better job of regular handwashing (actual washing, rather than “Purell” propaganda, in vogue today).
Failure of commencement of the ideas of Holmes, Semmelweis, and Lister is another cautionary tale for us today. A quote on a cover of The Lancet several years ago sums it up well: “The most entrenched conflict of interest in medicine today is a disinclination to reverse a previous opinion.” [Yudkin, Richter, Gale. Lancet 377:1220-1221, 2011.] While academic health centers have self-righteously implemented stern conflict of interest policies, we seem oblivious to the proven fact that it is not the ballpoint pen with drug company logos or the pizza from surgical suppliers at grand rounds that we have to fear, rather it is our own prejudices that close our minds to new ideas.



Three.           UMMS graduation.

Cropsey copy

[Above: University of Michigan Medical School. c. 1850. Cropsey painting.]

This month the UMMS will graduate its 166th class of medical students. Back in 1850, when Semmelweis spoke to an unreceptive audience in Vienna and cattle grazed in front of the Medical School in Ann Arbor, Michigan’s first M.D.s were about to go out to independent general practices in a world quite different than today. What inspired those students to study medicine then is a matter of conjecture for us now, but it is likely that role models, the ability to help people, the respectability of the occupation, and perhaps some attraction to body of knowledge of human disease, were motivational factors.
Those same motivational factors are at play for our class of 2016 about to graduate, but newer attractions such as the magic of health care science and technology, cures for cancer, and surgical wizardry including robotics, lure many of young people to medicine now. Some students are also inspired by deep personal and family health care experiences.
What is also different now from the 19th century is that after graduation nearly the entire class of 2016 will continue further formal education in residency training for 3-10 additional years before they are ready for independent work in one of nearly 150 areas of focused practice.
While the curriculum and conceptual basis of medical practice have changed enormously, the spirit of professionalism and necessity of continuous learning through experience, reason, and study have remained constant. Medical school and residency training are now just a start. Even back in 1850 medical societies and professional journals played key parts in what we now call professional development. Students and physicians, even more readily today, travel to distant sites of expertise to improve knowledge and skills. In today’s world, conferences, visiting professorships, and web-based educational programs intensify learning experiences as knowledge and technology accrue with dizzying speed.


[UM Health System 2016]



Four.           Role models.


This picture shows former Dean, Jim Woolliscroft and former Interim EVPMA, Michael Johns, at Medical School Commencement several years ago. As of January 1 this year those two jobs have been rolled into one, namely Marschall Runge (seen below), an equally great role model for students, residents, and faculty.


[Marschall at the Urology Retreat March, 2016 Michigan Union]
Jim will be our Medical School commencement speaker later this month and I’m sure he is focusing intensely on his remarks right around now. Our rich history at Michigan and the changing world of medical practice, education, and research may enter his speech, and I bet he will also have something to say about professionalism and the lifelong learning required of physicians today.
Role models often conflate into ideas and images of idealized doctors. Last month we contrasted Norman Rockwell’s idealization (shown below) to the crayon artistry of a 7-year old girl illustrating a clinic visit: the family is looking at the viewer while the physician is turned away facing the computer while dutifully documenting the encounter. In our brave new world of technology, computerized documentation is a poor surrogate for the essential transaction of the doctor-patient relationship. The classic role model of the attentive, kind, and expert physician will become only more highly prized and that should be the Michigan Difference in our medical graduates, trainees, and faculty.

Family Doc

It turns out that Rockwell’s idealized physician was an actual doctor named Donald Campbell and I learned this through Maria Muller of our development office, who wrote me after she read Matula Thoughts in March, that Dr. Campbell was the grandfather of a friend of hers.

1989 -- Stockbridge, MA: Dr. Donald E. Campbell, model for artist Norman Rockwell's illustrations, smiling, walking arm in arm with his daughters (L) Jeanie Campbell Jones and (R) Bonny Campbell Flower, who holds her daughter Hana. (Photo by Steve Liss/The LIFE Images Collection/Getty Images)

[1989 — Stockbridge, MA: Dr. Donald E. Campbell, model for artist Norman Rockwell’s illustrations, smiling, walking arm in arm with his daughters (L) Jeanie Campbell Jones and (R) Bonny Campbell Flower, who holds her daughter Hana. (Photo by Steve Liss/The LIFE Images Collection/Getty Images)]

         Campbell was Rockwell’s neighbor in Stockbridge, Massachusetts and for many years the sole regional physician, charging $2 for an office visit and $3 for a house call. Born in 1906, Campbell was educated as a physician and married, in time fathering 4 daughters. He retired at 83 just after making his last house call in 1989 and died in Stockbridge at 95 on May 14, 2001. [New York Times article May 16, 2001. Photo via Getty Images for a payment of $150]



Five.           Three stories.
After residency training at UCLA I went on to obligated military service at Walter Reed Army Medical Center under Ray Stutzman and David McLeod, enjoying my time so much that I stayed for an additional 2 years, leaving when Ray retired from the Army to join Patrick Walsh at Johns Hopkins. Dave is still in uniform in Washington.

Stutzman, DAB, McLeod

[McLeod, Bloom, Stutzman at USUHS]
At Walter Reed I re-encountered an older friend of my family who was working at its Institute of Research (WRAIR). This distinguished physician became my patient, in fact his was the last radical prostatectomy that I performed in an adult. Long gone now, he told me at the time that it had been his idea to create the weekly section in JAMA called A Piece of My Mind. How accurate this claim is I have no way to know, but without reason to doubt him I’ve been regularly attached to this column and frequently refer to its essays. Three recent ones are of particular interest.
  What Now? What Next? was written by a pulmonologist and medical intensivist at the University of Pennsylvania who became a patient in his own ICU and discovered, in the experience, that the current idea of shared decision making with acutely ill patients, especially on an a-la-carte basis (formal consents for central lines, transfusion, hyperalimentation, etc.) may be ill-advised: “I think we should bundle consent for the acute phase of intensive rescue. … Whether on a ski slope or battlefield, or in an emergency department, operating room, or intensive care unit, the foundation of respect for patient autonomy lies not in multiple permissions and consents, but rather in mutual understanding and trust. In the context of acute critical care – once the goals of care are clearly defined – we clinicians (thankfully, I am one of ‘us’ again) should not substitute asking permission at every step for the hard and time-consuming effort of earning trust.” [J. Hansen-Flaschen. JAMA 315:755-756, 2016]
The second essay, The Unreasonable Patient, came from a palliative care physician at the University of Pittsburgh and discusses a man in his early 50s with metastatic prostate cancer. At a terminal point in his life the patient, Walt, was viewed by the health care team as “unreasonable.” The author writes: It turned out that Walt wasn’t ‘unreasonable’ – he just wasn’t completely understood. After getting to know him better – after sitting and taking the time to explore his emotions and concerns – it was clear that Walt knew what he wanted, but he needed information in a certain way. He needed a recommendation without ambiguity, and he needed someone to speak to him as Walt the Husband and the Mechanic, not Walt the Man with Prostate Cancer. [A. Thurston. JAMA. 315:657-658, 2016]
I had initially missed the third essay, until it was sent to me by an extraordinary applicant to our OB/GYN residency. Caiyun Liao is an MD/ MPH doing research at Johns Hopkins and I got to know her through our Nesbit alumnus Sherman Silber. The article is called A Place to Stay and was written by Yale physician Bennett Clark. [JAMA 315:871, 2016] Clark shows how a patient taught him that what makes the hospital a hospitable place to live and die is “having people,” meaning having genuine human connections around him. This thought, expressed so much better by Clark than by me, circles back to Paul Kalanithi’s observation (last month’s Matula Thoughts) that, for many people, life’s meaning is found in their relationships and connections. These externalities bring meaning to our individuality.



Six.           Electronic journal club.
When I began this periodic essay for our Department of Urology, alumni, and friends in 2007 I thought it might serve as a sort of electronic journal club and I still harbor hopes that some readers will guest-edit a paragraph or entire issue to join me in this process. (What have you read that you want to tell the rest of us about?) These three articles from A Piece of My Mind are linked and offer much to consider.
Hansen-Flaschen’s observation as a patient in the ICU reflects a very particulate level of concern: My visual world reduced to the confines of a small room. The space was both familiar and foreign to me as I looked outward for the first time from the head of a hospital bed. There was both little and much to see. The clock showed the wrong date and time. The sink faucet dripped. Two ceiling tiles were stained by previous water leaks. The harsh overhead lighting cast yawning shadows that provoked my imagination. By comparison to Ebola wards in West Africa last year, the annoyances of inaccurate clocks, ceiling tiles, and dripping faucet are less compelling than the very matter of survival. Yet, in the industrialized world and most expensive health care system on the planet, I wonder why we can’t address these simple matters of hospitality. Our basic “hotel management” is too often inhospitable to patients. Even our newest hospitals can’t coordinate the clocks – why bother to have them if they’re correct only twice a day? Little things are important to patients and visitors, such as working elevator lights, paper towels in clean bathrooms, and general orderliness.
Another point to make comes from Thurston’s paper, when he said … after sitting and taking the time to explore his emotions and concerns… We use this phrase a lot – sitting down to talk and listen. Posture in space is not the point, this expression of speech conveys the idea that we are taking time (more time than might be usual or expected) by sitting down to listen and respond.



Seven.          Big questions.
Last month I asked you to consider what might be the big questions in health care and offered a short list with thoughts regarding the first question.
a.) What is health care?
b.) How should it be provided?
c.) How is it improved and how does innovation occur?
d.) How is it taught?
e.) How is it funded and how are escalating costs managed?
The second question follows naturally; if you consider all the things that comprise health care and then imagine the various avenues society can use to provide those things, you need to decide what health care goods every human in a society should have by right. Few could argue that clean air and water, food safety, prevention of communicable disease, along with maternal and pediatric care, are mandatory for everyone in a modern just society. So, too, is care for trauma or other general hazards of life.
At the other extreme, some services are purely discretionary – such as Botox for wrinkles or plastic surgery for facelifts. However, things get complicated because Botox for neurogenic bladder is sometimes very necessary, as is plastic surgery for craniofacial reconstruction. No insurance system or single payer system can reasonably satisfy the overall demand for health care – from the fetus to the end of life, the demand curve for health care and the therapeutic possibilities in our toolkit are growing relentlessly. A variety of systems and avenues are necessary, but wise choices need to be made and agreed upon as to what services are mandatory public goods, what services are discretionary, and what robust systems can provide these facets of health care.



Eight.           Harvey & hearts.

Screen Shot 2016-04-26 at 4.28.40 PM

Four hundred years ago William Harvey, the English physician we referred to last month, began a series of anatomy talks as Lumleian Lecturer at the Royal College of Physicians in London. By coincidence William Shakespeare died just the following week at Stratford-on-Avon. [JAMA 315:1524, 2016] Harvey continued to study and learn while he taught and practiced medicine and 12 years later, in 1628, published some extraordinary findings, cleverly introduced at the annual book fair in Frankfurt, Germany, to ensure wide publicity and dispersion. He offered a novel explanation for the systemic circulation based on the pumping of blood from the heart to the body and brain. The short title of the book was De Motu Cordis, but you will find it on Amazon as On the Motion of the Heart and Blood.
Harvey was on my mind last month since his birthday was on that entertaining first day of April, back in 1578. Those were dark times in Europe with civil wars, witchcraft persecution, and sectarian violence, but the spirit of inquiry and discovery was not quiescent. Francis Drake was circumnavigating the globe and European universities were holding their own, for the most part, nurturing ideas and preparing for the next generation that would include Harvey and other bright lights.
Harvey came to mind again when I read a review of a new novel called The Heart, by Maylis de Kerangal, a French writer. Being on the road at the time (visiting professor in Houston at Baylor) and intrigued by the review, I succumbed to the temptations of Amazon and ordered the book (apologies to local booksellers Literati and Nicola’s Books). The story takes place in a single 24-hour period, much like the Homeric Odyssey, but it happens in France when a 19-year old dies after a motor vehicle accident. The book runs from the instant the young man wakes up to join friends for morning surfing to the moment the team that transplanted his heart to an older woman leaves a Parisian operating room. The accident and subsequent transplantation of the heart involved many individuals, including the boy, parents, girlfriend, doctors and nurses in the rural hospital, transplant coordinators, transplant teams, and recipient in Paris. The victim and all these people have their own metaphorical “hearts” in terms of their feelings, motivations, and hopes. The personal tragedy, families, health care teams, and hope are all knitted together around a single human heart that transcends the story. The story is compelling, although the translation and a few technical details fall short. Urologists have a place in the story as the anchor positions in the operating room sequence of the multi-organ harvest.

Screen Shot 2016-04-26 at 4.32.15 PM

A final Piece of My Mind reference: Louise Wen’s article 2 weeks ago in JAMA, called Meeting the Organ Donor [JAMA. 315:1111, 2016]



One of the pleasures of academic medicine is the chance to visit great centers of excellence and learn from them while teaching residents. I’ve done my share of these tours, and as my career winds down. I don’t expect to be doing many more, but recently enjoyed such a chance to visit Baylor Medical School and friends at Methodist Hospital. Fannin Boulevard in Houston is one of the world’s greatest constellations of health care assets, a tribute to the life and vision of the great cardiac surgeon, Michael DeBakey (1908-2008), role model to thousands of students, trainees, and colleagues. His surgical and educational contributions are unsurpassed in world-wide medicine. DeBakey’s knitting ranged from Dacron grafts to clinical, educational, and research institutions that resulted in the combination of Baylor Medical College, Methodist Hospital, St. Luke’s Hospital, MD Anderson Cancer Hospital, superb urology training programs at Baylor and the University of Texas Houston, Ben Taub Hospital, Hermann Hospital, Texas A&M programs, etc.
The balance was sadly disrupted by governance and leadership blunders, severing the cherished Baylor-Methodist bond. As a result Methodist Hospital of Houston, oddly now, has its academic affiliation with Cornell in Manhattan. The unfortunate story, well recounted in a weblink the residents sent me, could well have been our misfortune at Michigan as one of the perpetrators had been selected by a former UM president and Board of Regents to be our EVPMA, but withdrew in favor of a better deal from Baylor. [Weblink: courtesy Michael Brooks PGY 5 at Baylor- Article in Texas Monthly, March 2005, by M. Schwartz. The marriage of Baylor College of Medicine and Methodist Hospital should have been made in heaven—and until recently, it was. Their nasty breakup is a bell tolling for American medicine.]
In spite of the institutional breakup, urologists and their educational programs in Houston get along very well and gave me a great 3-day visit. Edmond T. Gonzales, Jr., the founder of pediatric urology in Houston, had been the first partner of Alan Perlmutter in Detroit. Edmund is a wonderful role model as a pediatric urologist, teacher, and leader. By a rare coincidence he, Ed McGuire, and Jean DeKernion had been on the same dormitory floor as young men in college together in New Orleans.

Baylor fac & DAB

[Above Baylor faculty; Below Baylor case conference. Edmond – top right]

Res Conf

Boone & Bloom

[Above: with Tim Boone. Below: two old friends now in Houston – David Roth chief of pediatric urology and former intern with me at UCLA, Brian Miles former resident with me at Walter Reed and later colleague at Henry Ford Hospital]

Roth & Miles


[Above: Chester Koh at robot performing pyeloplasty on pancake kidney in the Edmond Gonzales operating room. Below: Residents at dinner.]

Residents dinner

[Below: Michael DeBakey, museum photo]


Harvey, DeBakey, and thousands of physiologists and physicians who followed have extracted increasingly detailed knowledge of the heart as a living physical entity, but it takes imaginative exploration of the heart’s metaphysicality, such as Maylis de Kerangal’s penetration of this realm, for complete understanding. Fiction thus builds a better understanding of reality.



Ten.           UMMS & Department of Urology Notes.
Since Jim Montie’s era as chair transitioned to mine in 2007, our department has grown with only modest attrition consisting of Humphrey Atiemo to the Henry Ford System, Jerilyn Latini to Alaska’s Indian Health Service, Dave Wood as CMO of the Beaumont Hospital System, and Jill Macoska as endowed professor at the University of Massachusetts. In terms of joint faculty we lost Ken Pienta to Johns Hopkins. This year, however, we lose four more of our best. Nevertheless, our fulltime faculty will nonetheless grow to around 40 after the loss of Gary Faerber and his wife Kathy Cooney to Salt Lake City (Kathy, our joint faculty member, became chair of Internal Medicine and Gary joined the urology team there), Cheryl Lee to become chair of urology at Ohio State, Stu Wolf to help form a new medical school of the University of Texas at Austin, and the irreplaceable Ann Oldendorf is retiring. On the plus side, Sapan Ambani, Casey Dauw, Priyanka Gupta, Chad Ellimoottil, Arvin George, and Sam Kaffenberger will join our faculty this summer and more candidates are in play for FY 17.
Why the growth? Several reasons: A.) Our 7 clinical divisions, although already robust, need more bench depth to accommodate our growing clinical needs and future faculty turn-over; B.) Increasing sub-specialization demands more people in areas of tightly focused practice; and C.) Our newly reorganized UM Health System needs a larger clinical footprint to sustain our educational programs and to remain relevant in the new paradigm of American health care.
Residency training programs learn from each other through the recurring interchanges of visiting professorships, national meetings, research collaborations, migrating students and trainees, etc. It is nonetheless healthy for programs to undergo more formal evaluations through internal reviews and external reviewers as we have done recently with Bradley Leibovich of the Mayo Clinic, Mark Litwin of UCLA, and Ed Sabanegh of the Cleveland Clinic. They were superbly analytical and very helpful.

Bradford, Carol

Most recent news: Carol Bradford, our chair of Otolaryngology, was named by Marschall Runge and the Regents as inaugural Executive Vice Dean for Academic Affairs, as the UMMS puts a new structural paradigm in place.

Thanks for looking at our monthly commentary for May 2016.
David A. Bloom, University of Michigan, Department of Urology

April First, 2016

DAB What’s New April 1, 2016

Hearts & hoaxes, questions & bells


(4073 words)


One.  Noteworthy births.


The first of April  has a small share of notable birthdays for physicians, scientists, and others who impacted the human condition. A name that rings a bell is William Harvey (1578) shown above. This English physician produced the first accurate description of the function of the heart and  circulation of the blood in his book, Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus [Painting attributed to Daniel Mytens, 1627. National Portrait Gallery London] Predecessors back to the time of Galen had gotten the physiology wrong, but Harvey was forgiving in his discovery, telling students: “Not to praise or dispraise other anatomists, for all did well, and there was some excuse even for those who are in error.” French mathematician Marie-Sophie Germain (April 1, 1776) produced pioneering work in elasticity theory and Fermat’s Last Theorem. Bismarck (1815) and Rachmaninoff (1873) came along as April firsters in the 19th century. Joseph Murray (April 1, 1919 – November 26, 2012) was a plastic surgeon and close friend of my old professor at UCLA, Willard Goodwin. When I was a resident I naively thought Joe was somewhat out of his league in his yearly travel group of old friends that included Goodwin and Robert McNamara, until Joe got the Nobel Prize for his work with renal transplantation.

DAB Murray copy

[Above: Joe Murray visiting UM & young faculty member out of his league. Below: 2 legendary Michigan coaches – Steve Fisher & Bo Schembechler]

Bo & Fish copy

Bo Schembechler (April 1, 1929 – November 17, 2006) is, of course, legendary for us at the University of Michigan. More controversial is Abdul Qadeer Khan (April 1, 1936), a Pakistani physicist who disseminated nuclear weaponry to rogue nations of the world.

Unlisted so far in the Wikipedia tallies for April first birthdays is Paul Kalanithi (April 1, 1977 – March 9, 2015), author of a current best-seller When Breath Becomes Air. Finishing residency in neurosurgery at Stanford the author discovered he had metastatic lung cancer. The book has a simple structure: a prologue, Part One In perfect health I began, Part II Cease not till death, and then an epilogue by his wife Lucy.

We each quietly contemplate deeply personal questions related to what might be described as the meaning of life, but circumstances gave Kalanithi urgency to come to some resolution. He exposes his thoughts with literacy and without self-pity. The meaning of life he discovered for himself lay in what he called human relationality. The context of one’s life is what matters, he believed, and it is from relationships with others that we derive meaning. Physicians and other health care providers should have a head start in the personal search for meaning, if you accept Kalanithi’s view, although many don’t understand that advantage. A spiritual person at the end of life may derive comfort from a religious faith or from a faith in the order of the universe and, perhaps, a reassuring sense of the circle of life as the Lion King said. On the other hand a cynical person might claim that faith is only a hoax we play upon ourselves and that each of us should grab whatever we can before our individual turns at life are over. No one can genuinely tell anyone else what the truth actually might be, we each must figure it out for ourselves. That individual worldview is what makes each of us what we are, each of our presidential candidates what he or she is, what the pope is, what El Chapo is, and it made Paul Kalanithi what he was.


Two.              Happy New Year.

For reasons lost in the deep recesses of history, the first of April has become a day for harmless pranks and hoaxes. April was the first full month of the new calendar year until only a few centuries ago. In Europe and during the Middle Ages March 25 was considered New Year’s Day. Possibly the natural human bent for trickery consolidated around that yearly transition. Japan begins its new year on the first of April and for this reason Dr. Takahiro Osawa and his family now return to Sapporo after 2 productive years with us in Michigan. We will miss him.

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Taka tells me that April pranks are also a tradition in his country. April foolery has endured around the world since first alleged references in Chaucer’s Canterbury Tales in 1392.

Exactly 40 years ago (1 April 1976) during a BBC broadcast English Astronomer Patrick Moore predicted that a “Jovian-Plutonian gravitational effect” would cause a noticeable short-term reduction on Earth’s gravity. At 9:47 AM on that day (GMT), he announced, a momentary alignment of Pluto and Jupiter would decrease Earth’s gravity such that those who jumped into the air at that moment would experience a floating sensation. Soon thereafter, BBC received hundreds of calls from people who claimed to have had felt the effect. The story was revealed to be a hoax, but Moore was a believable prankster and 4 years later he co-authored a totally factual book on Pluto with Clyde Tombaugh, who had discovered the dwarf planet in 1930.


[Pluto, NASA image. North polar region at top. Notice the large bright Tombaugh Regio, nicknamed The Heart, lower right of center.]

The idea of fluctuating gravitational fields was prominent in Kurt Vonnegut’s book Slapstick (published in 1976, the same year as Moore’s hoax) and if you notice cyclic patterns in human behavior you might find some validity in Vonnegut’s satirical hypothesis. A prediction 100 years ago along a similar line was made by Albert Einstein. Stemming from his theory of general relativity he predicted the idea of gravitational waves that could transport energy in the form of gravitational radiation. Hypothesis rather than hoax, it took a full century to prove this idea. On February 11, 2016 the LIGO and VIRGO Collaboratives announced discovery of a gravitational wave from a pair of black holes that spun into each other 1.3 billion light years away. The wave passed by the Earth this past September 14 when it was noticed initially by Marco Drago, a 33-year old Italian Physicist in his office at the Max Planck Institute in Hanover, Germany. [A. Cho. Science. 351:797, 2016] Teams and collaborations of thousands of people spent over 100 years seeking a gravitational wave, although Drago was the first to notice the anomalous signal, and even then his first thought was that it was a glitch or a trick.

Our ability to sort out truth from myth, stories, hypotheses, hoaxes, science fiction, propaganda, and blatant deceit is constantly being tested. April Fools’ Day offers a playful “reset button.”


Three.           The heavy human footprint.


[USGS Water Science School]

Winter is officially over and while we did have some cold days, it wasn’t quite as cold or snowy as my memory tells me it used to be. Of course all things change and many of them cycle, whether sunspots, seasons, or climate. It is no hoax, though, that the Earth is in a warming spell and that anthropomorphic effects on the planet are driving that and other detrimental changes. Curiously, large swaths of the population, including many elected leaders in our nation, deny the fact of significant environmental change due to human influence.

Earth, with a volume of 2.6 x 1011 cubic miles and a mass of 1.3 x 1025 pounds, is the densest planet in the Solar System with a mean density of 0.2 pounds/cubic inch (5.5 grams per cubic centimeter). While the origin of planetary water is still unknown and it seems so vast, its 3.3 x 109 cubic miles represents only 0.0013% of the earth’s volume, merely a thin wet veneer over part of Earth’s surface. (1 cubic mile = 1.1 trillion gallons)


The image above comes from the USGS website (Water Science School). The big blue sphere represents all of earth’s water, the smaller sphere over Kentucky represents total fresh water, and the tiny bubble over Atlanta estimates the fresh surface water in lakes and rivers – this being what most of us 7 billion earthlings have available for drinking or washing. [Credit: Howard Perlman, USGS; globe illustration by Jack Cook, Woods Hole Oceanographic Institution © Adam Nieman.] Ice caps, glaciers, and permanent snow account for 5,773,000 cubic miles or a little less than 5.8 x 107 m3, or 17.6% of the earth’s total water.

During the last ice age, when Michigan was a mile deep below the Laurentide Ice Sheet, sea level was about 400 feet lower than it is today. At the other extreme, if all land and sea ice melted the ocean level would rise 70 meters or 230 feet. However you choose to describe it, the environment is changing rapidly and dangerously due to the heavy human footprint. This is no hoax or conspiracy.

A fragment of a speech from John F. Kennedy has resonated with me throughout my adult life: “For in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s futures. And we are all mortal.” I recently asked my colleague and Kennedy scholar Kevin Loughlin for the origin of the quote and he immediately referenced Kennedy’s American University speech (titled A Strategy of Peace) on June 10, 1963. The president at the time had only a little more than 5 months to live. Flawed no more or less than most presidents or the rest of us, JFK did have inspiring intellect, clarity, and a way with words.


Four.             Ann Arbor notes.

In April 1985 my family and I had been in Ann Arbor for less than a year. Having accepted the job here as an associate professor (without tenure) I was still getting over the sting of finding myself demoted to assistant professor by the Medical School Executive Committee after arrival, but that’s another story. The Section of Urology was a terrific environment, Ed McGuire was a great boss, pediatric urology at Michigan was going well, and I loved my colleagues here in the medical school. The community was an excellent fit for Martha and our children, and we quickly found great friends. I distinctly remember the hoopla about a local restaurant, the Pretzel Bell, closing that April. This picture below from the old Ann Arbor News (used recently in Michigan Today) shows people lined up for an auction of Pretzel Bell memorabilia, necessitated by the IRS because of fraud related to employee withholding taxes. The article in Michigan Today by James Tobin explains that the original proprietors, John and Ralph Neelands, hung an old bell, said to have dated back to Civil War times, in the tavern. The story went that Fielding Yost had come to own the bell and gave it to the Neelands, after ringing it at Ferry Field. Ann Arbor has a rich German history and German university beer gardens traditionally featured two signs of hospitality – a bell to call in neighbors and a basket of pretzels.

pretzel bell Apr 1985

New ownership and management is resurrecting the Pretzel Bell and it should reopen soon to delight a new era of aficionados as well as old timers, for whom the name will ring a bell.

The University of Michigan has two bell towers (the original and the one on North Campus). The Bell Tower Hotel, across from the original, was the first place I stayed in Ann Arbor, when Ed McGuire invited me in 1983 to look at a pediatric urology job. A key predecessor of mine in the job had been Ed Tank, and his next-door neighbor back then, Dennis Dahlmann, now owns the hotel and has turned it into quite a gem. Ed Tank has retired in Portland, Oregon after a great career in our field. His excellent surgical results, the trainees he inspired, his academic productivity, and his organizational leadership constituted an extraordinary and admirable career. Ed’s successor in Portland, Steve Skoog, had been my resident at Walter Reed and is now a close friend and colleague. The coincidences in life are often beautiful.


[Above: Bloom & Tank. Below: Skoog and Dennis Peppas, former student of mine at USUHS, now pediatric urologist University of Texas, San Antonio]

Skoog copy 2


[Below: Dennis Dahlmann & Bill Martin 2015]

Martin & Dahlmann


Five.              Metrics & mission.

A flawed general assumption in the business world is that an organization can be run, optimally, by cost-based accounting. If, in fact, all decisions could be based on numbers (metrics, as it is often said) then a good computer could replace all managers. Businesses, however, run based on people, relationships, and their stories at least as much as any numbers. Alon Weizer referred with irony to his excellent efforts at managing the Cancer Center ambulatory care unit (the largest in the UM Health System.): “it is easier to manage by metrics, rather than digging down into the stories behind them.” Of course we cannot ignore numbers and have to pay attention to them, they are a key part of our information intake, but they are hardly the only form of our intelligence. The idea of running a business from the central organizing principle of managerial cost-based accounting, rather than managing it according to mission, customer-based deliverables, and lean-centric employee engagement has been a damaging conceit of 20th century industry. Yet, paradoxically, just as managerial accounting is phasing out of forward-thinking businesses as the central operational paradigm, it has been colonizing the brains of health care system managers.

At our Urology Department Retreat 2 days ago, we grappled a bit with the importance of financial margin and the need to defend and expand our markets on one hand, but with the central values of mission and essential deliverable (kind and excellent patient-centered care) on the other hand.

David Spahlinger got us started at noon with an overview of our health system reorganization and urgent strategies. Marschall Runge closed the program around 6:30 with a lively Q & A session. Our health system and medical school are fortunate to have great top leadership at this point in time.

Screen Shot 2016-03-30 at 7.57.18 PM

[Retreat at Michigan Union]


Six.                 Bellmen.

We need leadership but too often find odd characters coming forward offering their services to take charge of our governments and more immediate organizations. Having studied and experienced great and poor leadership I’ve become somewhat cynical of those who have a pressing need to lead me. The cautionary tale of the Bellman is fitting. He was the captain of a ship’s crew in Lewis Carroll’s The Hunting of the Snark. His map of ocean (a blank paper) and contradictory navigational orders did not inspire his crew, but his rule of three (“What I tell you three times is true.”) helped lead them into strange territory. Sometimes it feels like this for those of us taking care of patients in large health care systems.


[Cover of first edition Hunting of the Snark by Lewis Carroll 1876. Hendry Holiday, the illustrator born in 1839, died 15 April 1927]

Lewis Carroll, a mathematician, delighted in nonsense and intellectual pranks and he no doubt relished that irony. The beauty of math and science is their pursuit of verifiable truth. Bellmanism may work well in primitive societies, but it fails in free, just, and scientifically-educated societies. A modern bellman can say whatever he or she wants, as many times as they want, but for the rest of us to accept a claim, verification or proof is necessary. Trust but verify, is the adage we often hear. Scientists are rigorous about this way of thinking.

Thinking about statements and proofs, a long time ago Pythagoras proved that a2 + b2 = c2 for any right-angled triangle and most of us not only remember this is true, but we can actually prove it by a few examples or tests. A French lawyer and mathematician, Pierre de Fermat (1601-1655), asked himself: if a2 + b2 = c2 then can this be true for higher integers; in other words does a3 + b3 = c3  and is this equation generalizable for all powers? Fermat thought not and his conjecture was written in the margin note of a book in 1637, but his proof was apparently not recorded although he must have convinced himself that Pythagoras’s hypothesis only holds for special cases (like the number 2). For more than 350 years other mathematicians, including Marie-Sophie Germain, tried to figure it out, but failed until Andrew Wiles successfully proved Fermat’s conjecture in 1994.

Medical practice aspires to evidence and logic over Bellmanism. Nevertheless, much of what we do has to find a balance within a Pythagorean triangle of decision choices. On one side we rely upon our personal training and individual experiences. Another side (with far fewer options) offers evidence-proven therapeutic choices. The third side entices us with cutting-edge innovations. In the fast action of clinical practice we will usually default to the hypotenuse of our training and experience. The reality of clinical practice today falls short of the math; that is present-day clinical evidence plus cutting edge innovative technology does not equate to individual training, experience, and reason. Yet while this larger side may be our first resort, we need to condition ourselves and our students to remain self-critical and vigilant for old faulty dogma and new ideas that are better.


[a= cutting edge innovation, b= verifiable high level evidence, c= training & experience]


Seven.          Health care questions.

What are the big questions in health care? As health care in this country undergoes significant changes, dictated by a variety of forces, it may be useful for us to consider health care not in the context of metrics (e.g. RVUs, length of stay, and cost per case), but rather in terms of our basic expectations and values. If most citizens and practitioners can understand and agree upon the larger questions of health care, the answers and the structures to provide them may come to us more readily.

I don’t think it should be up to any one subset of “the experts” to tell us the questions, for after all, that’s a sort of Bellmanism. The key questions should be derived more broadly, they do not belong solely to universities, medical schools, or schools of public health. They do not belong to state or governmental legislative or regulatory agencies. They do not belong to the AMA, the ACS, the AUA. They belong to the public – to citizens, patients, health care providers. My first loyalty lies within the last broad categories as a citizen, patient, and physician – memberships that convey measures of authority in offering, just now, a set of basic questions for our collective consideration. Whether these are the right questions is a matter for you to consider. What among them is right, what is wrong, and what is missing?

  • What is health care?
  • How should it be provided?
  • How is it improved and how does innovation occur?
  • How is it taught?
  • How is it funded and how are escalating costs managed?


Eight.            Choices.

While there may be no simple solutions for these questions, and whereas the “devil is in the details” clarity can be found in their deliberate articulation and informed public discussion. The first question is deceptively simple, but what of “health care” is a public good and in the public interest? Certainly vaccination for dangerous diseases, TB surveillance and therapy, mosquito control, and Ebola management should be public goods. When is health care screening – screening for TB, hypertension, or malignancies (which malignancies) – in the public interest? What basic commodities of health care must be assured to the public (to assure the public health) and what are the discretionary choices that should be paid for by the responsible recipients of those services? And what about recipients who are incapable of such responsibility? Is not antenatal, obstetric, and well-child care in the public interest? Who should make these decisions?

The time-worn bogeyman of “socialized medicine” has seen its day; socialized medical care has a heavy footprint in today’s USA and its called Medicare, Medicaid, Tricare, and the Veterans Administration. Pressing questions are related to funding, equity, and scope of each of these systems. The present binary argument between a single payer system or an insurance-based model, in my opinion, is wrong.

A single payer system, while convenient from the point of funding and health policy, is fraught with many problems, among them being loss of personal choice, dependence on politically-set budgets, restriction of innovation, and lack of competition. On the other hand, the idea of building an entire national health-care system on an insurance-based paradigm is faulty since basic health care (this first question, after all) is a complex life-long responsibility extending from antenatal months to the last days of life. Insurance for rare and unexpected catastrophes like liver transplantation, motor vehicle accidents, ALS, renal failure, and serious malignancy makes sense, but not “insurance” for expected life events such as childbirth, vaccinations, dental care, routine checkups, and screening for certain diseases. The bipolar choice could be compared to asking us to choose between the Post Office or Federal Express as the single national mail delivery service. Neither one alone would be a good provider. The competition between them and other delivery services makes each one leaner, more innovative, and more customer-centric. Health care of our population needs many avenues to be universal, fair, excellent, efficient, and innovative.


Nine.            An epilogue.

The epilogue to Kalanithi’s book, written by his wife Lucy, included one phrase that struck me: “Although Paul accepted his limited life expectancy, neurologic decline was a new devastation, the prospect of losing meaning and agency devastating.” [p.203] Ultimately, for most of us, those two things are what life boils down to – the meaning we find in life and our agency to do things that are meaningful to us and to others. Meaning is our ability to make sense of things. Sense-making may be a matter of simple practicality, knowing for example that 1+1=2, or it may be the more existential making-sense of our lives. Kalanithi made fine sense of his shortened existence. Lucy Kalanithi ends her epilogue in the book powerfully enough to make your eyes well up: “Paul’s decision to look death in the eye was a testament not just to who he was but who he had always been. For much of his life, Paul wondered about death – and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.” [p.225]

The content, style, and literacy of Kalanithi’s book makes it compelling and readable. Coincidentally, the book is visually accessible because of its typeface, which is called Bell, after John Bell (1745-1831) who produced the original design, described as: “a delicate and refined rendering of Scotch Roman” at the book’s conclusion (above quotation is bold Bell MT font on my computer, although via email or the WordPress blog site, deformation is expected).


Ten.              Tolling bells.

Cancer, sectarian violence, motor vehicle trauma, and heart disease remain high on the list of the Grim Reaper’s tools. Nearly 400 years ago last month (March 31, 1631) the cleric and poet John Donne died, from stomach cancer it is believed. Born in 1572, 6 years before Harvey, Donne grew up and lived his 59 years through difficult times amidst terrible sectarian conflict that makes our recent western paradigm of separation of church and state so praiseworthy. During the reign of Elizabeth I (1558 -1603) the Recusancy Acts, beginning in 1593, imposed punishment on those who didn’t participate in Anglican religious activity, extending to imprisonment and capital punishment. (These laws were ultimately repealed in 1650, although restrictions against Roman Catholics lasted in England and Wales until full Catholic Emancipation in 1829.) Donne’s parents were Roman Catholics, but the father died when he was four and John’s mother married a wealthy widower, Dr. John Syminges. Donne studied in Oxford and Cambridge but never graduated with a degree as he was unwilling to take the Anglican Oath of Supremacy. He then studied law in London. Donne’s brother Henry, a university student, was arrested in 1593 for harboring Catholic priest William Harrington. Under torture Henry betrayed Harrington who was tortured, hanged, and disemboweled in 1594. Henry Donne died in Newgate Prison of bubonic plague.


[Lots on his mind. John Donne c. 1595. National Portrait Gallery, London]

John Donne became an Anglican minister, Dean of St. Paul’s, and a poet. (His interesting later years were chronicled by Izaak Walton, author of the first book on fly fishing.) What’s relevant from Donne is Meditation XVII in Devotions upon Emergent Occasions that included this familiar phrase that is linked to Kalanithi’s idea of human relationality: No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.”


Thank you for reading What’s New and Matula Thoughts for this April 1, 2016