Matula Thoughts June 6, 2014

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Challenges of FY 14, leadership, conflicts, & our successors.

1. Not so long ago fiscal year 2014 loomed large as an ominous transition point in health care with the collision of multiple forces of major impact. The rising rate of spending relative to GDP, the struggling world economy, climate change, expensive new pharmaco-technology, increasing economic and healthcare disparities, aging populations, the growing complexity of the health care work force, unintended consequences of large scale legislative health care legislation, underfunded necessities of research and education, duty hour dysregulation, are only some of the many forces that quickly come to mind. Other factors are less immediately obvious, but no less significant. New appreciation of the complexities of chronic disease management has rendered our models of health care delivery archiac (e.g. the primary care-specialty care model, employer based coverage, and even the very idea of “an insurance model” to manage health care for a large population). The effects of gerrymandering in determining election outcome, and hence legislation and public policy, similarly have impaired the public good. All of these things have come together now, more than ever before, to destabilize the economy and structure of healthcare in the United States.

2. Nevertheless, this feared watershed fiscal year is in it’s final month and, for the most part, the essential transactions of health care delivery – clinic visits, medication prescription, diagnostic testing, operative procedures, provision of supplies, education, research, and innovation are still happening on a daily basis even though this work seems to be done against the grain with increasing difficulty. We will soon have our FY 14 numbers (patient visits, operative procedures, RVUs, grant dollars, satisfaction scores, papers written, patents claimed, operational margins, days of cash on hand, etc.) and analysis of these will show us where we stand. However it comes out, even if our fiscal head is above water which we expect, we will be standing well below our potential as a department, as a medical school, as a health system, as a university, as a state, and as a nation. Irrespective of the constraints of the larger environment (including our self-inflicted wounds of the HITECH Act, legislative gridlock, and reactive regulation such as the duty hours story) we have the ability and duty to our patients, trainees, employees, community, and our children to do our work better. While the FY 14 boogeyman didn’t bring the world to a screeching halt, we still need to rapidly find new ways to maintain the missions of academic medicine – clinical care, education, and research. Underpinning all this is our essential deliverable: kind and excellent patient-centered care, thoroughly integrated with education and innovation at all levels. If we get this right, one patient at a time as well as one system at a time, then most everything else we want will follow.

3. Today’s date, June 6, is a big anniversary for a far more monumental watershed point in time for mankind. Operation Overlord was launched on this day in 1944. Had this massive organizational feat failed the world would be very different today. In fact it’s leader, Dwight David Eisenhower, was not so sure of success given the myriad contingencies in play beginning at the launch of Overlord exactly 70 years ago and he accordingly prepared an alternative brief statement on July 5 to be released in case of failure: “Our landings in the Cherbourg-Havre area have failed to gain a satisfactory foothold and I have withdrawn the troops. My decision to attack at this time and place was based on the best information available. The troops, the air and the Navy did all that Bravery and devotion to duty could do. If any blame or fault attaches to the attempt it is mine alone.” Eisenhower offered no optics, spin, or scapegoats.
[The Eisenhower mea culpa never needed to be sent.]

4. Eisenhower was not unchallenged as a leader or soldier even though he had the trust of Roosevelt and Churchill. His British counterparts were demeaning: Bernard Montgomery said “Nice chap, no soldier” and Alan Brooke proclaimed that Eisenhower knew nothing about strategy and was “quite unsuited” to be Supreme Commander. In retrospect, those comments seem to reflect mere petty jealousies as the outcomes of Eisenhower’s leadership at that key point in time dwarf any accomplishments of those detractors. Leadership matters greatly. While leaders have great latitude in times of relative peace and stability, they have consequential impact when times get tough. The world today would most likely be very different had it not been for Eisenhower, Roosevelt, and Churchill seventy years ago, and the same holds true as such for Lincoln and Washington in their times as well. Much more recently and locally look at Bill Ford and Alan Mulally for extraordinary leadership success. On the other end of the spectrum leaders of very different character such as Pol Pot and Adolph Hitler hijacked their constituencies and neighbors into terribly dark days. This is evidence of the problematic duality of our species. We are the only one of the rare eusocial species who can deliberately select leaders and determine our governance – but that is another story, better told by E.O. Wilson. [Two books of reference: a.) Anthony Beevor. D-Day. The Battle for Normandy. b.) Edward O. Wilson. The Social Conquest of Earth.] [Pictures – Normandy beach 70 years ago and same beach and American Cemetery on my visit in 2010]
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5. Leadership was at play last month at the AUA national meeting in Orlando, on many podiums and in many committee sessions. One noteworthy example was the Michigan Urological Surgery Quality Collaborative (MUSIC) conceived by Jim Montie and “Eisenhowered” by David Miller. At the MUSIC session I saw urological colleagues participating from around the state including a number of our own former students and residents. Dr. Miller and Dr. Brian Stork gave excellent presentations, highlighting the beautiful social/scientific collaboration of urologists who have, through trust and hard work, pooled their individual and local experiences to figure out to deliver better care at better value in collaboration with Blue Cross/Blue Shield. This should be a model for the future in health care. Especially inspiring was to see how MUSIC has brought private practitioners to podium presentations and to authorship positions thus erasing the “barrier” between the academic and non-academic sides of urology. Leadership has also been in play with Stuart Wolf’s amazing work overseeing the AUA guidelines. Prominently visible was the running video on guidelines showing Michigan faces throughout the AUA including Stuart, Quentin Clemens, and Ann Gormley. John Park’s Mott video was also running outside the pediatric sessions, showing Julian Wan, Vesna Ivancic, and Kate Kraft as well as John Park and Carla Garwood, representing our pediatric nursing team. A video also showed members of the prostate SPORE group. The Reed Nesbit Society held its reception on Sunday night. This has become a lovely annual habit and is financed by both the Department of Urology and the Nesbit Society. This year we hosted around 120 people. Friends of the department, new and old alumni, faculty, and residents acquaint or re-acquaint themselves. If you missed it this year consider joining us in 2015 in New Orleans on Sunday, May 17. Perhaps the biggest news of the meeting was the awarding of the AUA Gold Cystoscope to our Associate Professor Will Roberts later in the convention. Ed McGuire received this honor back in 1982, so out of a total of 38 Gold Cystoscopes, Michigan Urology now accounts for two. David Miller was awarded the Society of Urologic Oncology (SUO) Young Investigator Award. Ted Skolarus, Jeff Montgomery, Florian Schroeck, and Khurshid Ghani were awarded Best Abstract at the 2014 VA Forum. Bahaa Malaeb, Aruna Sarma, and Rod Dunn received Best Poster Award for their work on the relationship between diabetes and sexual dysfunction.
[Photo by Wendy Roberts]

6. National meetings of specialties are the fundamental marketplaces for the ideas, products, and talents of healthcare processions. Large organizations such the AUA, ACS, ASCO, AAP, EAU, or SUO may seem like an alphabet soup to outsiders, but they are the interfaces between today and tomorrow for medical specialties. Each year in between the meetings faculty, residents, and research teams develop ideas, create hypotheses, test products, and perform other acts of scholarship even while doing the never-ending daily work of clinical care and education of our successors. The chance to stand at a podium and present one’s observations to the world of urology at large is a big moment for residents, and aggregation of those moments develops reputations and careers for faculty. Michigan Urology had a big year at Orlando’s AUA meeting. We used to try to count the number of appearances for our faculty, residents, and students at this meeting and found the count running well beyond 100, but this year I won’t even try that little exercise of hubris. The bottom line is that Michigan Urology’s people and ideas are a major force in this marketplace of urology. I had too much fun talking and taking pictures at our Nesbit reception so I deferred my brief “State of the Department” presentation for an appendix in this “What’s New.”

7. The AUA national meeting is heavily subsidized by urologists as well as the corporate world. We and our departments spend big dollars on the research that produces the talks. We also pay travel expenses for the faculty, residents, and nurses who give the talks and listen to others. The practice of urology is a profession that exists within the social industry of healthcare. We depend upon social opportunities such as this annual meeting to exchange and stimulate new ideas, to see new products, to network for new opportunities, to find jobs for our trainees, and to develop collaborations. While replete with opportunities, the interfaces of the medical profession, industry, and academia have ethical risks. We are all human, and some of us test boundaries of self-serving behavior more than most others. A smaller number, reflecting the dark side of our duality, wander into territories of mischief or even deliberate wrongdoing thus rules are necessary. We recoiled when we read about the Ivy League professor promoting his (unacknowledged) proprietary antihypertensive drug to a class of medical students as THE drug of choice, or learn of an orthopedic surgeon routinely using his own invention in patients without full disclosure of his commercial interest. Our own institution is not blameless as seen recently by the professor in another department who gave confidential drug trial results to hedge fund operators that allowed insider trading. These people are scoundrels and dirty our profession. Not all conflicts are purely monetary and some are conflicts of commitment. It is not uncommon for many of us to try to wear too many hats, even though our heads are only finite in dimension. In fact we each actually do need a few hats, for rain, cold, construction work, mosquito protection, etc. Ego, however, makes us overestimate our head size tempting us to accept a few too many. You could call this phenomenon the hat trick of ego or perhaps “the blinding effect of arrogance”, a risk for each of us.

8. Academia and industry need to intersect for the public good. We sometimes manage this intersection well and other times not so well. One good example is histotripsy, a technology invented here at Michigan by a team including our own Will Roberts, along with radiology and biomedical engineering colleagues. As a department, Michigan Urology has invested a decade of time and money in Will and this idea. Ultimate product development, however, exceeded our capacity and required initial venture capital to the tune of $11 million. Within only about four years now clinical trials for BPH are underway (with full disclosure) at a number of sites – Tim Schuster in Toledo (Nesbit 2004) did the first histotripsy prostate enucleations. We have a thorough conflict management plan that details the extent of our departmental involvement in this product development and its trials. We are doing this well and properly. It is important to develop good standards to manage conflicts of interest and conflicts of commitment, although ultimately we must depend on shared values and appropriate behaviors. [Actually, and somewhat unfairly, the University of Michigan through its policies rather than our Department of Urology, will assume most of any financial gain if HistoSonics Corporation is successful.]

9. Although I was present at the discussions and votes around our medical school’s new conflict of interest policy, I was uneasy supporting the stipulation that faculty, residents, and nurses must refuse hosted social occasions at national meetings. As we prepared to go to the AUA meeting messages went out that our new conflict of interest policy warned against accepting food or drinks from the pharmaceutical and industrial representatives who otherwise would be with us in Orlando supporting the meeting. In the past I have freely enjoyed the hospitality of, for example, the Olympus Corporation with our representative Bill Herpek while on other occasions I’ve picked up the check for the burgers he and I had at the concession stands in the exhibit halls. Bill has become a friend and colleague for 25 years, quickly available for replacement scopes in the OR when urgent repairs are necessary, or finding us good deals (in the world of competitive bidding) when we need new technology. The extent of our mutual hosting has really been nickel and dime, not paid excursions, serious gifts, or stock options. (In full disclosure he did give me a wildlife calendar once.) Might someone assume that our friendship or the burger I bought him translated into a sweeter deal for the cystoscopes we purchased? Doubtful – but our relationship does provide a basis for fair deals and open communication. It’s not just our own Michigan policies that don’t seem quite right. When we had Marston Linehan here recently for a Von Hippel Lindau symposium, NIH policy required him to pay for his own dinner at the event. Given the shenanigans of Congressional and other leaders, I am embarrassed by the double standards. Our colleague here at the University of Michigan Charles Eisendrath tells us that in his journalism career the self-imposed standard was that “if you can’t eat it or drink it, you shouldn’t take it.” On the other hand the egregious exploits related to insider trading I mentioned earlier involved far more than cheeseburgers, but I’d contend they didn’t begin on the ”slippery slope of a lunch” at a national meeting, but rather involved cozy self-serving deceit right from the start. How about participation on heavyweight national boards by university leaders? I have heard the many “pros” of the argument, but really our top academic and health system jobs are not only quite well compensated but they also seem to be demanding enough on a 24/7 basis. Yes the interface between academia and industry needs to be somewhat fluid, and yes leaders “can learn things” and develop relationships on major boards. On the other hand, proper board service is demanding of time and commitment, things that might be more reasonably offered when individuals are no longer in the pilot’s seat for a major enterprise. The hat trick of expertise is an alluring illusion and we are each susceptible to its temptations. No policies or laws can substitute for a good internal compass, although any compass can be swayed by strong elemental forces (iron, silver, or gold). An essential part of our jobs as teachers and role models in the health care industry is the duty of imparting a strong moral compass to our successors. As I look at our Nesbit alumni – it seems that Michigan Urology has done this well for nearly 100 years.

10. Our foundational mission at the University of Michigan Medical School and Department of Urology is to train our successors, and the evidence of our success is beautifully visible each year at the Nesbit AUA Reception. As you know, the context for education of our successors is necessarily the practice of medicine amidst the innovation of the science, technology, and systems of healthcare. Our essential deliverable of all this is kind and excellent patient-centered care, thoroughly integrated with innovation and education at all levels. The basic building blocks of education are medical school and residency training. Michigan’s medical school graduation took place just a few weeks ago and our 169 graduates will go out to start their residencies in the next few weeks. Michigan students are highly prized in training programs around the country, reflecting the excellence of our medical school and the departments in which students discover their careers. The match rate this year was 100%, meaning that all Michigan students were accepted by the training programs they sought. Of these 28% will stay at Michigan for training and 32% will remain in our state. The others will go to top programs around the country.

Five Michigan medical students went into Urology this year: Denise Asafu-Adjei to Columbia University Physicians & Surgeons in New York, NY; Spencer Hiller to Beaumont Health System in Royal Oak, MI; Zachary Koloff to University of Michigan in Ann Arbor, MI; Kola Olugbade to SUNY Downstate Medical School in Brooklyn, NY; and Brian Orr to Indiana University Medical Center in Indianapolis, IN.

Of our four new urology interns coming to our program: Ella Doerge from Baylor College of Medicine in Houston, TX; Zachary Koloff from University of Michigan Medical School in Ann Arbor, MI; Ted Lee from New York University School of Medicine in New York, NY; and Parth Shah from University of Texas Medical School at Houston, TX. Michigan residencies pick the strongest students from other schools as well as ours – of the interns that entered in 2013 for all specialties here 41% were members of AOA, the medical school honorary society.

We have three new fellows: Sapan Ambani from University of Michigan for a two-year endourology fellowship, Lindsey Herrel from Emory University for a three-year urologic oncology fellowship, and Yahir Santiago-Lastra from Massachusetts General Hospital in Boston as a clinical program trainee in the female medicine and reconstructive surgery (urology) for two-years.

Graduating Chief Residents: Sapan Ambani will be staying with us for an endourology fellowship. Dan Miller will be doing a fellowship in endourology and minimally invasive surgery at the University of California San Diego/Kaiser Permanente. Jackie Milose is going to Northwestern in Chicago for a GURS Fellowship. Matt Smith is headed to Muskegon to work with the team of urologists at West Shore Urology. Fellows: Nina Casanova is completing her pediatric urology fellowship. Florian Schroeck is joining the faculty as an Assistant Professor in the Department of Urology at Geisel School of Medicine at Dartmouth. Anne Suskind is headed to UCSF on the faculty as an Assistant Professor in the Department of Urology.

The highest step in the academic ladder is the rank of Professor and this title was granted by the University to Quentin Clemens, Khaled Hafez, Brent Hollenbeck, and John Park. Jeff Montgomery became an Associate Professor. Academic promotions are recommended and approved by each departmental promotion and appointment committee, then by one of the three Dean’s Advisory Committees (the faculty vote on memberships for these), then by the Medical School Executive Committee (also elected by faculty vote), then by the Provost, and finally by the Regents. These promotions are effective September 1.

Best wishes, and thanks for spending time on “Matula Thoughts.”

David A. Bloom, M.D.

What’s New April 5

What’s New April 5, 2013

Michigan Urology Family 

Looking at things – asteroids, racehorses, A3s, and other matters.


  1. I’m very glad to be back to work after my mini-sabbatical. What was I doing during this hiatus from day-to-day tasks? Mainly I was focused on an analysis of what I think is an existential threat to our department, specifically a gap between our current clinical footprint today and where our clinical footprint needs to be to serve the needs and aspirations of our department. The time away from our front office allowed me to take a 30,000-foot view of Michigan Urology. Plus I was able to read and think deeply, as well as to reflect and set a course for the balance of my term as chair. I’m appreciative to John Wei and our two other associate chairs Gary Faerber and Stuart Wolf as well as my pediatric urology colleagues who covered for me. I last had a mini-sabbatical at home in 2000, just before my 7 year interlude as Associate Dean. This time I went to Charleston, SC for 2 months. A friend visiting asked me: “What do you want to accomplish?” My answer: “Three things. One, I want to complete my A3 analysis of the departmental gap I’ve been worrying about. Two, read deeply, and three, come back with new energy and ideas obtained from one and two.” One small product of the time away had been this blog which will house our monthly “What’s New” broadcasts and offer a chance for your comments. On the table you can see the A3s in preparation –> IMG_5339
  2. Michigan Urology is centered on a four-part mission that we have been fine-tuning for a good number of years.  We recently hammered out a new version of our mission statement that considers the key components of education, clinical care, discovery, and leadership. Of course once we assume the responsibility for clinical care it then becomes the moral trump card that can displace any of the other parts of the mission at any given moment or day. The essential deliverable of our mission thus becomes patient care – kind and excellent patient care, integrated with innovation and education at all levels.
  3. The A3 analysis is a method from the Toyota Production System that I learned at our Lean Training here at UM and at the Lean Enterprise Institute in Cambridge, MA last summer when I attended with John Park. As a health system, as a Faculty Group Practice, and as a department we have been heavily engaged in these ideas and methods. The A3 (named for a size of paper on which one executes the problem solving) is an excellent method of analysis that is just as suitable to health care and academia as it has been for manufacturing industries. My A3 is titled: “Our clinical footprint is falling short of our needs and aspirations as a department of urology.” My reading list evolved into a talk for our Senior Clinical Management (SCM) Group and the A3 Report will be the subject of our Faculty Retreat on April 26. If you are interested let me know and I’ll send you a copy of the SCM talk. The A3 turned out to be one primary A3 and four separate “baby A3s.”
  4. History has much to teach us, it is sometimes greatly entertaining and stimulating, and it can be reassuring. For example, we have confidence in today (April 5, 2013) and the week ahead because history allows us to guess that a hurricane, devastating earthquake, or catastrophic meteor impact are unlikely. The guessing is not random, it is a matter of prediction or forecasting that depends upon data, analysis, and intuition. Of course we recall the recent hurricanes Sandy, Irene and Katrina, or winter storm Nemo, none of which came out of the blue – all were predicted reasonably well. However, this week and indeed the next few months should be free from hurricane anxiety. Charleston was hit by a devastating intraplate earthquake August 31, 1886 of an estimated 7.3 magnitude. History and science allow us to predict that a large magnitude earthquake is a 1-in-600 year event for Charleston (although a 1-in-30 year event for Anchorage, AK). Nearly everyone knows about the meteor impact that wiped out the dinosaurs and the 1908 meteor that flattened a forest 2/3 the size of Rhode Island in Tunguska, Siberia. Yet the world was surprised just six weeks ago on February 15 when astronomers were tracking a known asteroid called “2012 DA 142” (the size of a football field and a half) as it was about to pass within 17,100 miles of Earth. The surprise was that unexpectedly from another direction a different unknown asteroid (the size of a bus) slammed into our atmosphere (thus becoming a meteor) and exploded over Chelyabinsk, Siberia injuring over 1200 people. (Why Siberia so often? Is it just big, or unlucky, or both?) So, while history can give us some predictive confidence in the future, prediction is not necessarily reality or truth.
  5. cave_painting_V1_240x160 copyOf course, from catastrophe and destruction come novelty, innovation, and evolution.  An alleged meteor (10 kilometer or 6.2 miles in diameter traveling 30 km/sec) impacted off the Yucatan peninsula 65 million years ago) and caused a mass extinction that knocked off the dinosaurs giving evolutionary opportunity to small mammals, then larger ones including primates.  A few primates expanded the use of tools, communication, and imagination far beyond their predecessors and here we are. The artwork of our earliest forefathers, dating back nearly 30,000 years, is astonishing. The horse illustration shown above from the Cave de Chauvet, of which I’ve spoken here before, is a prime example. What was the ancient artist trying to communicate? To my eye it seems to be horses in motion, although the artist was clever enough to achieve that sense without showing the legs of the horses. Horse racing is a beautiful thing and an evocative image. Organized horse races might have been a wild dream for some of those cave dwellers – the idea of controlling wild horses and holding a race must have been a wild fantasy at first, but it soon became reality soon after the first horses were domesticated.  Imagination, innovation, team play, and leadership over the millennia that followed brought that dream and hundreds of thousands of other fantasies to fruition.
  6. The silver lining of the great meteor and mass extinction took more time to play out than you and I have at hand so in our short-term view a big meteor slam would be very bad news. Extending the possibilities of natural disaster a bit more, one could argue that the seeds of our potential destruction could come not just from out of nowhere (asteroids) or from within (earthquakes). Equally destructive disaster can come laterally from our atmosphere (hurricanes, tornados, and tropical storms).  In an analogy for Michigan Urology the asteroids might be the world and national socioeconomic threats, perhaps even reflecting the sequelae of climate change. The earthquakes might be internal disruptions and instabilities arising in our university and health system. The atmospherics could be construed as turbulences within our department. If our powers of forecasting and prediction were better for asteroid impacts, earthquakes, or the weather we could take that information to the bank and craft strategies and tactics to protect ourselves. If my own predictive powers were better I could guarantee protection of our mission.
  7. Most mission statements throughout our medical school and health system are tripartite, beginning with our founding educational mission as a university and as a medical school. Of course great education must begin with self-education and discovery, thus discovery and research are surely part of our mission. Furthermore, unlike many other types of education, medical education cannot be separated from its practice. Within only 19 years of its founding, the University of Michigan Medical School realized that it needed a hospital to stay ahead in the game of medical education. Thus UM became the first university to own and operate a hospital, which has today become a multi-billion dollar health system. Medical education at Michigan began with a single “product” of the MD,  but it soon came to include residency education that today is the career-defining element of medical education. While we have around 650 students in our medical school we have over 1100 residents and fellows training in our health system at any given moment.  Somewhere along the line, UM picked up the slogan “leaders and the best.” This is really more than a slogan, it is a fact attested to by our history and our present belief in our medical students, residents, and faculty today.  So it seemed proper and fitting to add leadership to our mission statement as a fourth attribute.
  8. Gimcrack detail copyLeadership implies a contest or race, something of interest to our species since our earliest days. Of course we can never know anything of the life of that artist in the cave in what is now southern France, but he had a sharp eye and keen talent. This next painting shown is a detail is from a work by George Stubbs in 1765 of the horse Gimcrack on Newmarket Heath. Stubbs was then considered the greatest painter of horses. In the century after Stubbs, the understanding and representation of equine motion was no different, as this second race scene, by an artist named Charles Newdigate, shows (courtesy of the Edmondston-Alston House, Charleston, SC).         DSC_1585
  9. While our senses are pretty good at showing us how the world works, they are not perfect. Technology has given us more information. For example, Steve and Faith Brown, UM Fans extraordinaire, gave me an amazing book on the eye and art that got me thinking about art and illusion (“The Artist’s Eyes” by MF Marmor and JG Ravin). This led me to recall the groundbreaking photographic studies of motion by Eadweard Muybridge (1830-1904). Until his stop-action photos of a horse running, we humans had absolutely no idea how horses actually ran. Their gallop was too fast for our brains to sort out the position of their feet at any instant and at that airborne moment in particular.  Stubbs, Newdigate, and the rest of us consistently imagined the airborne moment inaccurately with the horse’s front legs extended forward and rear legs extended backwards. In 1872 Muybridge settled a bet for Leland Stanford and came upon the truth.
  10. Muybridge was born in Kingston-upon-Thames in England and emigrated to San Francisco, still the Gold Rush Capital, in 1855 becoming a successful bookseller. By 1867 he had become a successful photographer. In 1872 the former governor of the state, Leland Stanford, asked Muybridge to help him settle the question of whether all 4 feet of a horse were simultaneously off the ground while galloping. Stanford believed in the controversial idea that horses were capable of “unsupported transit.” The resulting photographic series of Stanford’s horse, Occident, not only proved the contention of unsupported transit, but also showed that at the unsupported moment during gallop all four legs were collected under the body rather than extended ahead of and behind the body as had been commonly represented in art. Stubbs and Newdigate’s work was terrific for their times, but artists can do better today, in terms of accuracy and representation of reality.Horse gallop copy
  11. Things that we have accepted and that worked well enough in the past, can be improved. In the world of health care many things must be improved as they no longer fit the changing world. How can we better understand patient care in terms of value stream analysis? What are the essential transactions of health care delivery and how can we improve them?  How do we standardize our clinical transactions without losing the professionalism of medicine and commoditizing the doctor-patient relationship? How do we better understand our other customers of health care – those parties beyond the patient such as the referring physician, the patient’s family, the third party payers, the patient’s employers? How do we eliminate waste? How do we make each and every clinical product rewarding to the patient, consistent and efficient? (What do I mean by clinical products?  These include that very central and essential interaction after the doctor closes the exam room door to talk to and examine the patient, but also informational web sites, the conversations with the call center, the check-in process, diagnostic procedures, operative procedures, consultations with colleagues, the consoling of a family, etc., etc.)  These matters need our immediate attention. Our clinical products are not as good as we have thought they are. Our attention, already spread thin, is being squandered by political-federal shenanigans, wasteful electronic medical records, bureaucratic claims processing, and the heavy footprint of corporate medicine among other ills.  We must reconstruct healthcare nationally – but that remains to be seen and is beyond my job description.  We can, however, reconstruct it locally in our own department.
  12. Let’s take, for example, the new patient visit and deconstruct it so as to reconstruct it. We have each developed and individually come to cherish patterns of clinical performance based on our teachers, role models, and personal experiences. But how sure are we that our performances and systems are equally cherished by patients. How consistent and efficient are we? What worked well enough in the past is unlikely to be the best in show of the future. So for the new patient visit, what are the 5 (let me pick arbitrary boundaries) initial greetings and ice breakers that patents value most? What is the typical “structure” of a new patient visit, what are its elements?  How can you be assured consistently, that patients have their questions addressed and fears allayed? What is the amount of “speaking time” that patients need in a typical visit – have you thought about that and how can you consistently create that? How do you structure your recommendations and plan? How do you hand off the patients to medical assistants, residents, nurses, or check-out clerks? What about the summary letter – does it clearly serve the needs of patient and referral physician, or is it an ugly, lengthy and formulaic computer-driven piece of epic nonsense? However, you answer these questions, it is beyond doubt that we can improve our game, make it more valuable, kind and consistent for patients, and eliminate waste.
  13. Life is short and we want to spend it valuably. This is as true for providers as it is for patients, and of course all providers at some times will become patients. In health care we want to do things well, efficiently, and valuably. Yet value is something that is ultimately very personal. Value is in the eye of the beholder. Economic value is a measure of benefit from a good or a service. (This is not the same as price.) More broadly value can mean a fair equivalent, it can mean the perception of relative worth or importance, it can be a numerical value, or it can be a human value. Personal and cultural values are more difficult to define. Personal values inform our individual sense of what is good, useful, helpful, important, or desirable. In the aggregate of a team, community, or society a set of values emerges to allow a collective sense of what is good, useful, helpful, important, or desirable.  Value theory distinguishes moral goods from natural goods (such as physical materials). When we ask “what does the patient value?” we ask a complex question, but it is the central question.
  14. Health care is in the midst of a period of creative destruction. The meteoric effect of the federally mandated electronic health record may prove to benefit the greater good of mankind someday, although it mainly now seems to be benefitting the specific good of  a few corporations. We are still recovering from the steep initial drop in clinical productivity and are learning to practice within the rigid burdens of the new systems. The present creative destruction, however, extends far beyond the electronic record with other powerful acronymic meteors such as the SGR, GDP, ACO, along with manpower concerns, millions of new “covered lives”, millions still uncovered, unfunded mandates, the crime of health-care forced personal bankruptcies, impoverished states, national deficit, and the impotence of partisan gridlock. Whew! There’s a lot on our health care plate. Our best response is really not a matter of stepping up our game, rather one of changing our game. I hope my A3, the A3s that follow, social media integration now in the works, as well some experiments to retool our clinical products will give us a leg up (like all 4 legs of the racehorse Occident) in this new world that’s upon us now.
  15. Department notes. I returned to the front office of  a changed Michigan Urology. John Wei has done a yeoman’s job of dealing with the daily work. We did experience a big loss as our esteemed professor, Jill Macoska, answered the call of the University of Massachusetts to move her laboratory to Boston and assume the Alton J. Brann Endowed Chair as Professor of Biological Sciences. This is a huge and well-deserved honor for her and, of course as Bo Schembechler would have said: Jill will always be a Michigan Woman.Screen shot 2013-03-28 at 1.31.46 PM
  16. More department notes. Last week Visiting Professor Dr. Rosalyn Adam, Associate Professor of Surgery, Associate Director of Urology Research from Harvard Medical School/Children’s Hospital Boston gave a great talk at Grand Rounds on “Signaling Networks in the Bladder: Implications for Cancer and Benign Disease.”  Last month our internal weekly “What’s New” profiled Gary Faerber, Associate Chair for Education; an update from Stuart Wolf and Quentin Clemens on the recent Urology Joint Advocacy Conference (JAC) in Washington, DC; Division of Endourology and Stone Disease update; and John Stoffel in the Division of Neurourology and Pelvic Reconstructive Surgery. Website:
  17. Even more department notes. In the spirit of change we are putting a toe into the social media world and we now have a Facebook page “Matula Thoughts” and we will be putting versions of the monthly What’s New here on this blog:

Best wishes and thanks for spending time on “What’s New” this weekend, and welcome to the MatulaThoughts Blog. I am grateful that others beyond my immediate team and family are willing to slog through these monthly “What’s New” essays. Naturally, my intent is to keep them interesting and your thoughts are welcomed.

David A. Bloom

First Post of Matula Thoughts

Reed Nesbit logoMatula Thoughts

Throughout the millennia of human history clues to predict the future have been highly prized, especially so when that future related to prognosis of disease and disability. External cues from the heavens, in the weather, via tea leaves, or with playing cards have played major parts in the prediction of health. The logic of using more immediate evidence from physical signs or bodily fluids was evident to early practitioners. Humans share the trait with most other mammals of daily personal interest in their urine and in situations of illness scrutiny of it was obvious. Hippocratic writings documented uroscopy, as it came to be called, 2500 years ago and over the ensuing centuries the practice attained imaginative prognostications as healers examined the gross characteristics of urine in flasks called matulas and speculated on the course of illness.  The visual image of a “piss prophet” gazing at a matula served as the main symbol of physicians in art until only about 200 years ago when the stethoscope replaced the flask as medicine’s badge of office.

We begin this electronic journal with a respectful tip of the matula to that original essayist Michel Eyquem de Montaigne who began his eclectic personal observations around  in 1572 when he was around 39 years of age. It is likely that Montaigne was well acquainted with physicians and matulas, as his father purportedly died of urinary stone disease and Montaigne himself began to suffer from them in 1578.

What impulses compel us humans to share our observations and thoughts may someday be revealed through the matula’s diagnostic successors such as the MRI and other marvels of imagination, but there is no arguing that those impulses are strong and prevalent in our species. This blog (finally, I have used the awkward term) is a new forum for the monthly email broadcast I called “What’s New” that I started in 2007 in our Department of Urology at the University of Michigan and with the help of friends have continued regularly since then.

These little spaces and sentences will be filled by things that a.) catch my attention and b.) I hope will interest some readers. For the most part this will be an alternative space and presentation of “What’s New.”

David A. Bloom March 26, 2013