Matula Thoughts August 2, 2019. Impressions

Matula Thoughts

August 2, 2019

Impressions & metaphors:

Thoughts from a UMMS faculty member
2224 words/20 minutes

 

One.

As a medical student, my first impressions of children’s surgery imprinted on my brain much like a duckling gets imprinted when it initially sees its mother, or whatever creature first walks by. I went to UCLA for surgery residency in 1971 and then to London for a year in 1976 to learn from David Innes Williams, a founder of pediatric urology (above, Shaftesbury Hospital, 1976). The experience was rich. At first I was as an observer and later served as a registrar, the UK version of my status in the U.S. Mr. Williams was the consummate professional and his attitude was reciprocated by patients, trainees, and staff. My first impression of “DI,” as we called him, was one of the perfect English gentlemen, with unparalleled expertise and skill in one’s field. I noticed that even the poorest families coming to see him dressed for the occasion, the men often wearing a coat and tie, and the children well-scrubbed up and disciplined. Formality was echoed by kind and polite staff (Sister Fay and Sister Val) and by Mr. Williams himself who invariably offered a proper English greeting.

Mr. Williams was always addressed as “MR. WILLIAMS”– the appropriate title for a surgeon in the British world of medicine since the days of King Henry VIII who chartered the Barber Surgeons Guild in 1544. The physicians (internists) had been chartered in 1522 and were addressed as “Doctor” and the surgeons, a very distinct class of practitioners were “Mr” back then and remain Mr. to this day. Additional medical customs and traditions persisted in the National Health System and when I was a clueless young American, a colleague then ahead of me in training, Mr. Robert Morgan, took me under his wing and kept me out of trouble. Just as British ways sometimes confused foreigners like me and American ways tended to befuddle the British who, for example, couldn’t understand why Henry Kissinger came to be addressed as Doctor.

I returned to London in 1986, as a young UM faculty member on leave under Ed McGuire, to serve as a locum tenens for several months. Sir David Innes Williams (above, recently knighted) had retired from a large administrative post in the National Health System (NHS) and his successor Phillip Ransley was the sole pediatric urologist in London. American colleagues were taking sequential turns filling the spot that soon became formalized with a second NHS pediatric urologist, who turned out to be Patrick Duffy, the registrar working with me those months in 1986. I was self-conscious to be sitting in the same chair and at the same desk Mr. Williams had used to see patients, but I seemed to be tolerated by staff and patients.

In the decade between my times working for the NHS, the dress code and sense of formality of the clinic visits had relaxed. Families were more causal in dress, perhaps reflecting acceleration in the pace of life, only occasionally putting on their Sunday best for clinic visits, more likely quickly assembled from work and school to rush to Great Ormond Street Hospital by tube, bus, or cab (rarely by car, because where could they park?). Nevertheless, greetings were not rushed, but rather were moments of catching one’s breath on both sides of the table, with casual inspection, mutual taking measure, and kind acknowledgements. Those first impressions the parents and children have of the physician/health care provider are lasting.

 

Two.

Life is a social business and medical practice and education are especially social. That’s why we have frequent visiting professorships, like the Duckett Lecture last month, with Chester Koh from Baylor. Chester spoke on medical devices and discussed cases with residents, who also observed his professionalism and communication skills.

[Above: Pediatric uroradiology conference with Chester; Below: Kate Kraft, Chester, John Park.]

The first words patient hear often set the stage for their entire relationship with a health care provider. It is no surprise that one of the more offensive introductory phrases patients report is: “Why are you here?” Clinicians never intend any offense, and I myself may have cluelessly used those words in past days, trying to figure out the needs of a patient. Health care providers have many pressures for excellence, self-education, relevance, academic productivity, and equanimity. Furthermore, they are belabored by systemic pressures that are, perhaps, the greatest drivers of professional burnout: organizational metrics, throughput demands, rigid schedules, mandatory web-learning programs (fire safety, compliance, “high reliability training,” new chaperone rules, opioid regulations, and other modules every year). Electronic health record systems set the stage – demanding entry of a chief complaint at the outset of each “encounter.”

To many patients, however, that first question, Why are you here, is a slap in the face, interpreted by some as an accusation (“why are you wasting my time?”) or is evidence of an unread letter of referral or poor preparation. Patients may be anxious, looking for reassurance, expertise, and kindness. Parents with sick children will be especially distressed and for them, “Why are you here?” is a poor choice of the starting position for the physician or provider. If you put yourself in the place of the mother in Gari Melchers’ painting after the hassle and expense of getting to the clinic with your baby, you might not respond favorably to that question. If the provider was, perhaps, “burned-out” from a busy clinic schedule, the electronic health record, systemic mandatory demands, and short ancillary staffing, it is very likely that the mother with the sick baby was equally stressed, if not more so.

[Mother and Child. Gari Melchers. C, 1906. Institute of Art. Chicago.]

 

Three.

White Coat Ceremony. The stethoscope, invented in 1816 by René Laënnec in Paris, is not just an effective tool for auscultation, it is an equally effective metaphor for listening, which is itself a metaphor for seeing, hearing, or otherwise sensing the needs of a patient and family. [Below: Laënnec, National Library of Medicine. Below: Laennec’s 1819 monograph.]

Laënnec died of cavitating tuberculosis at age 45 on August 13, 1826 in Kerlouanec, leaving a wife but no children. [Ariel Roguin. René Theophile Hyacinthe Laënnec (1781-1826): the man behind the stethoscope. Clin Med Res. 4(3):230-235, 2006.]

The meme of the physician as a listener and observer is worth preserving, especially in this day of corporate medicine and formulaic encounters based on electronic medical record work flow. To institutionalize this idea of listening, our medical school began giving all entering medical students top-of-the-line stethoscopes on their first day of school at the White Coat Ceremony on 2004. The instruments were gifts from the clinical departments and some friends of the medical school interested in the actual and metaphoric listening skills of our “next generation” of physicians. Some of the best listeners in health care are themselves hearing-impaired and have trained themselves to go beyond casual vocal encounter with patients to discriminating perception of their patients with all senses.

[Above & below: UM White Coat Ceremony July 27, 2019.]

White Coat Ceremonies date back only to 1989 when, at the University of Chicago, a professor complained that first-year students “were showing up in shorts and baseball caps … where the patients are pouring their hearts out.” Dean of Students Norma Wagoner responded by starting a ceremony where students were supplied with white coats and instructed: “for any session where we have patients present, we expect you to look like professionals, wear the white coat, and behave appropriately.” [Peter M. Warren. “For new medical students, white coats are a warmup. Los Angeles Times. October 18, 1999.]

In 1993 Dean Linda Lewis at Columbia University College of Physicians and Surgeons, joined with the Arnold P. Gold Foundation to sponsor a white coat ceremony that is mirrored in medical, dental, and osteopathic schools today, among many other health professional schools. (Today, many of these medical schools bear the new names of their modern benefactors.) The white coat as a uniform of a health care provider is importantly a symbol of personal hygiene and responsibility. [Below: White Coat Syndrome, 2008, by Pat Curry, RN.]

The matula was the most prominent symbol of the medical profession for 650 years, as evidenced in art of the times, until Laënnec’s stethoscope in 1816 and the white coat even more recently. What the prominent symbols of the healing professions will be a century from now remains to be seen, but with luck regarding human destiny they won’t revert to the Aesculapian staff and matula.

 

Four.

The moral universe. The compelling imagery of a moral universe is a comforting metaphor. In 1958 Dr. Martin Luther King wrote “Let us realize the arc of the moral universe is long, but it bends toward justice,” in The Gospel Messenger, noting it to be a known aphorism. He used it again in 1964 for commencement exercises at Wesleyan University. The phrase has a deep history, traceable to 1853 and “A Collection of Ten Sermons of Religion” by Theodore Parker, Unitarian minister, American transcendalist, and abolitionist. A book in 1918, “Readings from Great Authors,” quoted Parker. A columnist in the Cleveland Plain Dealer reiterated the phrase, but omitted the word “moral” in 1932. The phrase has been since repeated on many occasions such as in a 1940 New Year version by Rabbi Jacob Kohn in Los Angeles: “Our faith is kept alive by the knowledge, founded on long experience, that the arc of history is long and bends toward justice.” President Obama used the phrase and credited Dr. King in 2009. [Above: Chagall Windows. Art Institute of Chicago.] Whereas some things in life are described as “soul-crushing,” this phrase is soul-compelling.

The physical universe and the universe created by the collective brains of Homo sapiens overlap and the human one increasingly changes the other, at least for the present in the Anthropocene moment. The change is simultaneously creative and destruction – think Mona Lisa or the miracles of contemporary health care versus genocide and environmental deterioration. But if we accept the fact that the human universe is ours to create, then we must recognize that it is (it should be or it can be) a moral universe, thus validating the aspiration of King and those who came before and after him with this belief.

The idea of a universe is a human construction and belief in a moral universe is a particularly human invention. Not eager to invite liturgical criticism, few can deny that Homo sapiens has built extensively around concepts of spiritual faith. But such is the nature of our species to imagine, discover, plan, and pass the information we find and create along to successive generations. In that sense, it is up to us to build that moral universe within the gargantuan amoral physical universe around us.

 

Five.

Ann Arbor August. In much of the northern hemisphere, August is a time for vacation, although the modern workplace of 52 weeks and 365 days per year, and 24 hours per day, requires some people at work every minute such that August is no longer a month of universal leisure time. I recall that when the yearly calendar was unveiled to my surgical internship group at UCLA in July, 1971, the first vacation assignment (namely July), went to the most hyperactive of our class, who was expecting to dive immediately into the world of operating rooms, intensive care units, conferences, and clinics.

That intern was very displeased at being told to “stand down” for his first month. The rest of us, I suspect, would have been more accommodating. In the end, he accommodated just fine, and over the course of a distinguished career, Ron Busuttil ended up as chair of the surgical department at UCLA himself. Summer or winter today, the life of a resident provides more downtime and one expects that our new PGY1s will have time for the pleasures of Michigan this month and next.

The Ann Arbor Farmers’ Market (above), operating since 1919, is a lovely feature of our community – a perfect example of Adam Smith’s second-best quotation (a favorite of John Wei):

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

[Below: top, local farm sales; local idiosyncrasy – Wolf Man; bottom, Sweet Dirt – Melissa Richard’s Ann Arbor ice cream]

 

Michigan Urology has its own centennial this year. We begin this celebration next month, 100 years after Hugh Cabot came to Ann Arbor, recruited by Dean Victor Vaughan, and will conclude it in the autumn of 2020, to coincide with Cabot’s first academic year at the University of Michigan. Cabot brought modern urology to Michigan in the multiple dimensions of clinical care, education, research, and the international stage.

 

Postscript

Gari Melchers (1860-1932), whose Mother and Child was shown earlier, originally from Detroit, was awarded an LL.D. from UM in 1913. His impression of Victor Vaughan was presented to the university in 1916.

Melchers’s Theodore Roosevelt, originally in the Detroit Freer Collection, is now at the Smithsonian Freer-Sackler Galleries. [Donaldson BM. An Appreciation of Gari Melchers (1860-1932). Michigan Alumnus, Quarterly Review. 1934. P. 506-511.]

As you enjoy August we prepare for the Michigan Urology Centennial, marking the start of modern urology in Ann Arbor under Hugh Cabot.

 

• Centennial Celebration launch, Nesbit Society Annual meeting October 3-5, 2019, Ann Arbor.
• AUA Nesbit Society reception May 17, 2020, Washington, DC.
• Centennial Gala Celebration. Nesbit Society Annual Meeting, September 24-26, 2020, Ann Arbor.

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

Ga-ga now and then

DAB Matula Thoughts June 7, 2019

Ga-ga then and now

2172 words

[Above: Nesbit reception at 2019 AUA Annual Meeting in Chicago. Ice sculpture.]

 

One.             

Senior medical students are getting ready this month for the next big stage in their lives and careers, just as I did in June of 1971 heading west from Buffalo to Los Angeles, to start nine years of training at UCLA. I don’t recall much of the drive along the evolving interstate highway system, a vision of President Eisenhower only 20 years earlier, but the exhilaration of beginning something totally new with surgical residency under William P. Longmire certainly dominated my thoughts on the road. The intellectual and conjoined physical capabilities of surgery as a profession excited me. The first day of internship, in line to check in, I met fellow intern Doug McConnell and quickly befriended John Cook, Erick Albert, Ed Pritchett, Ron Busuttil, Arnie Brody, John Kaswick, Dave Confer and the rest of our 18 at the bottom of the UCLA training pyramid. Over the five-year process, we learned the knowledge base, skills, and professionalism of surgery through experience, teaching, study, and role models. In the blink of an eye 1971 has become 2019 and, suddenly I’m near the end of my career.

Reading Arrowsmith and the recent story of the Theranos debacle in John Carreyrou’s Bad Blood, I saw those protagonists wanting to change the world. My hopes in 1971 were not so grand, I just wanted to find my own relevance and hoped to become good in my career. Most people similarly want to make their mark in one way or another, through job, family, art, or community. Some, however, actually intend to change the larger world, although their idea of “change” may be someone else’s deformation.

Last month a large cohort of our University of Michigan urology residents, faculty, nurses, PAs, and staff met in Chicago at the annual AUA national meeting to learn, teach, exchange ideas, network, enjoy reunion, and circulate word of our new chair Ganesh Palapattu. The Michigan brand was strong with hundreds of presentations from our faculty, residents, and alumni. The MUSIC and Nesbit Alumni sessions were great gathering points. [Below: UM podium events with alumni Cheryl Lee, Jens Sønksen, Barry Kogan, and Julian Wan.]

Cheryl has been back in Ann Arbor this week as visiting professor.

A group of our residents and one incipient PGY1 were ga-ga at the AUA Museum booth. [Below in front: Juan Andino, Catherine Nam; back row: Adam Cole, Scott Hawken, Rita Jen, Ella Doerge, senior faculty member, Colton Walker, Matt Lee, Kyle Johnson, Udit Singhal.]

 

Two.

Surgery, the word, derives from Greek, kheirourgos, for working by hand and the term moved through Latin, Old French, and Anglo-French to become surgien in the 13th century. The epicenter of that world was the doctor/patient duality, based on an essential transaction as old as humanity with exchange of information, discovery of needs, and provision of remedies and skills. The knowledge base and tools are far better since Hippocratic times, but the professional ideals are much the same. It seemed pretty awesome to my 21-year-old self that I might one day be able to fix things with my hands like Drs. Longmire and Rick Fonkalsrud. History mattered to our UCLA professors who insisted that trainees know the back stories of each disorder and treatment.

New interns arriving next month, called PGY1s for their postgraduate year status, may have parallel thoughts to those of mine 48 years ago as they start their journeys. Pyramidal training models no longer exist – PGY1s can reasonably expect to complete their programs. Their experiences will be replete with contemporary expectations, notably patient safety, value propositions, clinical outcome assessments, co-morbidities, social determinants of disease, personal well-being, attention to patient experience, and teamwork with diversity, equity, and inclusion. Acronyms have proliferated, tools are more powerful, and regulation grows more burdensome. Nevertheless, essential transactions remain at the center of health care with needs of patients addressed by the knowledge, skills, and kindness of healthcare providers, one patient and one provider at a time.

While taking pride in the labels doctor, physician, surgeon, nurse, and physician’s assistant we realize now that teams of providers with many types of expertise congregate around each single patient, either immediately physically as “bedside teams” (in clinics as well), sequentially, or virtually (with office staff, coders, laboratories, or electronically). Teams offer exquisitely specialized expertise and “wisdom of crowds,” although patients often find no single person in charge of their care.

 

Three.

Patient safety was a given when I was a resident. It was wrapped up in regular Morbidity and Mortality conferences without explicit use of that phrase, patient safety. Around that time a young graduate student in sociology, Charles Bosk, embedded himself in an academic surgical team for 18 months to discover how surgery was learned, practiced, and lived at an unnamed “Pacific Hospital.” The result was his book in 1979, Forgive and Remember: Managing Medical Failure. Bob Bartlett, my friend and colleague in the Surgery Department, introduced me to it a few years later. A second edition in 2003 was reviewed by Williamson. [Williamson R. J Royal Soc Med. 97(3):147-148, 2004.]

Patient safety has grown since my internship from an obvious but unarticulated expectation to a distinct field of study modeled after other industries, notably aviation. Health care has learned much from other professions such as the concepts of safety culture, standardization of procedures, checklists, and so forth, although healthcare is more multidimensional and nuanced than those other worlds. Bosk recently reflected on the health care exceptionality in a Lancet article, “Blind spots in the science of safety,” written with Kirstine Pedersen, concluding:

“There is a science of safety to reduce preventable adverse outcomes. But health care also has an irreducibly relational, experiential, and normative element that remains opaque to safety science. The contribution of a kind and reassuring word; a well delivered and appropriately timed disclosure of a bad diagnosis; or an experience-based evaluation of a small but important change in a patient’s condition – all are difficult, if not impossible to capture in a performance metric. Accomplishing safety and avoiding harm depend on discretion, effective teamwork, and local knowledge of how things work in specific clinical settings. Finally, the successful practice of a science of safety presupposes in theory what is most difficult to achieve in practice: a stable functioning team capable of wisely adapting general guidelines to specific cases.” [Bosk CL, Pedersen KZ, “Blind spots in the science of safety.” The Lancet 393:978-979, 2019.]

 

Four.

The Michigan Urology Centennial is nearly here and the process of writing our departmental history has elicited many names and stories. Bookends demarcating any era may be discretionary choices and our starting point could easily be debated. Perhaps the first “urologic” procedure of Moses Gunn initiated this specialty at Michigan in the 1850s, or the first faculty appointments with the term lecturer on genitourinary surgery, held by Cyrenus Darling (1902) or clinical professor of genitourinary surgery by Ira Dean Loree (1907) might qualify. Unquestionably, though, the arrival of Hugh Cabot in the autumn of 1919 brought modern urology with its academic components to the University of Michigan. Cabot was the first to use the 20thcentury terminology, urology, at UM and he was Michigan’s celebrity in the field. He literally brought Modern Urology to Ann Arbor, as that was the name of his two-volume state-of-the art textbook of 1918, repeated in a second edition in 1924. Cabot probably didn’t anticipate becoming Medical School dean when he left Boston two years earlier, but his advancement was hardly accidental. A number of other prominent faculty members were well-positioned to replace Dean Victor Vaughan, but Cabot played his political cards well and won the job.

Frederick George Novy (1864-1957) was the strongest competitor. Born and raised in Chicago, Novy obtained a B.S. in chemistry from the University of Michigan in 1886. His master’s thesis was “Cocaine and its derivatives” in 1887. Teaching bacteriology as an instructor, his Ph.D. thesis in 1890 was “The toxic products of the bacillus of hog cholera.” After an M.D. in 1891 he followed the footsteps of his teacher Victor Vaughan as assistant professor of hygiene and physiological chemistry. Visiting key European centers in 1894 and 1897, Novy brought state-of-the-art bacteriology to Ann Arbor, rising to full professor in 1904 and first chair of the Department of Bacteriology. His studies of trypanosomes and spirochetes, laboratory culture techniques, anaerobic organisms, and the tubercle bacillus were widely respected. Our colleague Powel Kazanjian wrote a first-rate book on Novy.

 

Five.

Paul de Kruif (1890-1971), one of Novy’s students, bears particular mention. [Above: de Kruif, courtesy Bentley Library.]  de Kruif came from Zeeland, Michigan, to Ann Arbor for a bachelor’s degree in 1912 and then a Ph.D. in 1916. He joined the U.S. Mexican Expedition (“the Pancho Villa Expedition”) against Mexican revolutionary paramilitary forces in 1916 and 1917, then saw service in France with the Sanitary Corps, investigating the gas gangrene prevalent in the trenches of WWI. de Kruif returned to Michigan as assistant professor in 1919 working in Novy’s laboratory, publishing a paper on streptococci and complement activation.

Novy helped de Kruif secure a prestigious position at the Rockefeller Institute in 1920, to study mechanisms of respiratory infection. While there de Kruif wrote an anonymous chapter on modern medicine for Harold Sterns’s Civilization in 1922. The 34 chapters were mainly written by prominent authors, including H.L. Mencken, Ring Larder, and Lewis Mumford, so how de Kruif, a young bacteriologist (and non-physician), came to be included in this compilation is a mystery. de Kruif’s 14-page chapter, however, caused the biggest stir, skewering contemporary medical practice and doctors for “a mélange of religious ritual, more or less accurate folk-lore, and commercial cunning.” de Kruif viewed medical practice as unscientific “medical Ga-Ga-ism,” but his article was sophomoric at best.

Once de Kruif was revealed as author the Rockefeller Institute fired him in September, 1922. The newly unemployed bacteriologist came in contact with a newly prominent author, Sinclair Lewis (1885-1951), praised for Main Street (1920) and Babbitt (1922). Lewis was ready for his next novel and two friends, Morris Fishbein and H.L. Mencken, persuaded him to focus on medical research. Lewis, son and grandson of physicians, knew little of medical research, so Fishbein, editor of JAMA, connected Lewis to de Kruif. A bond and collaboration ensued for Arrowsmith (1925) in which a central character, Max Gottlieb, was modelled around Novy. Lewis gave de Kruif 25% of the royalties for the collaboration, but held back on sharing authorship, claiming that it might hurt sales. At the time de Kruif thought his share generous, but later became somewhat embittered as book sales soared with Lewis as sole author. [Henig RM. The life and legacy of Paul de Kruif. Alicia Patterson Foundation.]

Arrowsmith was selected for the 1926 Pulitzer Prize, but Lewis refused the $1,000 award, explaining his refusal in a letter to the Pulitzer Committee:

“… I invite other writers to consider the fact that by accepting the prizes and approval of these vague institutions we are admitting their authority, publicly confirming them as the final judges of literary excellence, and I inquire whether any prize is worth that subservience.”

Four years later, however, Lewis accepted the $46,350 Nobel Prize. His Nobel lecture was “The American Fear of Literature.”

Leaving lab behind, de Kruif became a full-time science writer, one of the first in that new genre of journalism. His Microbe Hunters, published in 1926, became a classic and inspired me when I read it as an early teenager, unaware of the controversies around it. [Chernin E. “Paul de Kruif’s Microbe Hunters and an outraged Ronald Ross.” Rev Infec Dis. 10(3):661-667, 1988.] Arrowsmith was re-published in 2001 by Classics of Medicine Library and Michigan’s Howard Markel provided the introduction. [Markel H. “Prescribing Arrowsmith.”]

 

Ga-ga notes

de Kruif’s adjective ga ga for American medicine in the 1920s intended to mean foolish, infatuated, or wildly enthusiastic. It can also denote someone no longer in possession of full mental faculties or a dotard. (Dotard recently came into play in the peculiar rhetoric of the North Korean and American leaders.) The ga ga origin may be from early 20thcentury French for a senile person based on gâteux, variant of gâteur and hospital slang for “bed-wetter.” Gateau, of course, is also French for “cake” and gateux is the plural. de Kruif himself was negatively ga-ga with his criticism of medical specialism. Lady Gaga brings the term to a new level of consciousness and a new generation.

The past week was big on three continents for those who go ga-ga over historic anniversaries. Two hundred years ago, on 31 May 1819, Walt Whitman was born on Long Island. His Leaves of Grass, among much else, had the intriguing phrase “I am large, I contain multitudes,” a prescient reminder of our cellular basis, microbiome, or the plethora of information that leads to TMI (“too much information”) or burnout. Seventy-five years ago, on 4 June 1944, Operation Overlord at Normandy, France, initiated the Allied invasion of Nazi-occupied Europe. Thirty years ago, on 4 June 1989, protests in a large city square between the Forbidden City and the Mausoleum of Mao Zedong turned violent and are now referred to as the June Fourth Incident in the People’s Republic of China.

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

May 3, 2019. Sensations

Matula Thoughts  May 3, 2019

Sensations

 

2180 words: twenty minutes to read, five to skim, or seconds to delete if TMI.

 

Appreciation. Leonardo da Vinci reverberates strongly, even five hundred years after his death on 2 May 1519. The Lancet commemorated yesterday’s anniversary with a cover picture of that great polymath who encompassed astonishing ideas, insights, and talents, leaving for posterity a multitude of works that amaze and delight. Anatomy, physiology, engineering, and visual art are just a few of the intellectual arenas his senses played with and his hands produced. Walt Whitman later wrote: we “contain multitudes…,” and you can fill in the words of what multitudes in particular might follow, such as atoms, cells, thoughts, physical creations, emotions, or other possibilities. da Vinci exemplified that human potential better than most of us, trying to make sense of the world.

 

One.             

Azalias 2019

Spring hits our senses. We can’t easily describe in words the perfumes of flowers or the pleasant rich scent of mulch, but we surely know them. Odors are important sensory inputs, although we don’t usually notice them much as they are less important for us than to most other creatures.  [Above: azaleas, spring 2019.]

Dogs, for example, discern far more olfactory notes than we do and that is probably a good thing, since dogs sequester significant cerebral space and energy for distinctions of specific urine scents or fecal aromas to understand who is in the neighborhood, skills that have been essential to millennia of canine culture, while humans have found other ways to evaluate their fellows and territories. [Below: Molly’s spring inspection.]

Molly

We surely would be confused by having to track of hundreds of scent variations. In fact, even a small amount of effluent odor from one of our neighbors is generally regarded as too much information. [Below: mulch delivery at Smithsonian Institution, Spring 2019.]

Mulch

Smell used to be important in medical diagnosis. Uroscopy relied on smell, color, sediment, feel, and taste of urine for clues to disease and prognosis. Historically, urine was inspected by all five senses (including the taste of urine and the sound of its stream), but now patients are told to leave a sample in the privacy of a bathroom for a medical assistant to label and send to a laboratory. Doctors rarely come close to the stuff. Even so, for any good diagnostician, a necrotic wound, uremic breath, fecal odor, or hint of tobacco, are valuable bits of information not just for a specific disease, but also relevant to the life and comorbidities of a patient. These and other points of data add to the medical gaze that transcends visual clues and once inspired the meme of clever detectives. That gaze has now been replaced by the digital gaze of checklists, smart phrases, and drop-down menus.

RueMorgueManuscript

Last month we commented on the first of the medical detectives in The Murders in the Rue Morgue, wherein Edgar Allen Poe in 1842 described how diagnostic senses could be marshaled in a process he called ratiocination to figure out crimes. The tale reflected on the odor of urine and double entendre of a name when detective Dupin explained to the narrator (Poe) how he seemed to read his mind, by making deductions from facial expressions:

“Perdidit antiquum litera sonum.

I had told you that this was in reference to Orion, formerly written Urion; and, from certain pungencies connected with this explanation, I was aware that you could not have forgotten it.”

The Latin phrase intended the loss or attrition of an old or previous meaning or sound of the word or its homonym. Orion referred to the celestial constellation (Poe called it a nebular cosmogony) and its similarity to urine became a play on words that Dupin noticed had popped into the narrator’s mind as he looked up at the constellation and smiled when the wordplay and associations came to mind. [Above: 1895 facsimile of Poe’s original manuscript for “The Murders in the Rue Morgue.” Susan Jaffe Tane collection at Cornell University. Public domain. Wikipedia.]

 

Two.

Five classic senses taught in my childhood – smell, sight, taste, hearing, and touch – have been updated to seven for my grandchildren with the addition of vestibular sense and proprioception. Technology extends the senses further, outsourcing them and merging their inputs to provide unprecedented amounts of information of the world around us and within us. Microscopy and telescopy carry sight far beyond the unaided eye, while modern imaging with CT scans, MRI, and radioisotope labeling visualize our own living interior bodies. Sound, too, allows inspection of our interiors due to the discovery of Pierre Curie and his brother in 1880 of the piezo-electric principle in crystals that underlies ultrasonography. Extending the seven “basic” senses through technology, we see the world in new ways, although at the cost of diminished acuity of our original senses.

Today’s versions of the medical gaze and the detective’s ratiocination, are powerful: the sum-total of sensory inputs (enhanced by technology) and mental heuristics of scientific thinking.  Intellect integrates the physical senses. This larger sense, the sense of making sense of everything, is the wisdom, judgment, and mental capacity that creates meaning from immediate or recalled sensory input. This may be the most important and defining human sense, but even that is challenged by impending extension or replacement with so-called artificial intelligence.

 

Three.

Ghost_In_The_Machine_cover 

Incidental or relevant? Recently, I was asked to comment on a paper regarding incidental findings of renal cysts in children and that got me thinking how far ultrasonography has come in my career. Genitourinary imaging by ultrasonography came of age as a practical urologic tool in the 1980’s. I recall those early days when, at Walter Reed Army Medical Center, we experimented with crude B-mode ultrasonography to interrogate testes for tumors or viability. Coincidentally, it was around that time, 1981 to be specific, when Gordon Sumner wrote the lyrics to a song called Too much information (TMI):

“Too much information running through my brain,

Too much information driving me insane…”

The world is even more replete with information since Sting and The Police recorded that song in their album Ghost in the Machine. Yet, one might argue that TMI is a sophomoric complaint, as if the infinite information in the cosmos should be curated for our personal capacity of the moment. The actual problem is not too much information, but too little human capacity for processing and our technologies have made this situation worse.

Kandel

Perhaps this is the essence of abstract art, that Eric Kandel expressed in Reductionism in Art and Brain Science, explaining that functional MRI shows human brains process representational art differently and in different cerebral pathways than processing abstract art (Columbia Press, 2016).  Representational art gives viewers very specific images that relate to things immediately understandable. (Below: American Gothic by Grant Wood (1930), courtesy Art Institute of Chicago.)

 

“Abstract art” seems to contain less information (perhaps less craft – or even no craft, at first glance) than representational works. Kandel finds that abstractions can in fact contain far more, calling on you to search everything you know to understand the piece. Abstract artworks invite you to inspect the world to discover their meaning, although a particular artist may not necessarily know or understand the world any better than you. The artist, however, creates a door for you to imagine the world differently than you did a moment before viewing the work. Abstract images may open up, in an informational sense, far more than a given representational scene or a moment you will readily comprehend. Abstraction is a window into far larger and stranger worlds of information, associations, and imaginations. (Below: Composition No. 10. 1939-1942, (Piet Mondrian. Private Collection. Wikipedia.)

Piet_Mondriaan,_1939-1942_-_Composition_10

edu-meet-me-volunteers

[Above: UM Silver Club members attend Meet Me at UMMA program at the University of Michigan Museum of Art. Image courtesy of UM Silver Club. The untitled painting is by Mark Bradford, 2005.]

 

Four.

The Shannon number, named for UM graduate Claude Shannon (1916-2001), represents a lower bound of the game-tree complexity of chess, 10120.  This is an enormous number, unimaginably large, given that the number of atoms in the observable universe is estimated at 1080. The point here is that human imagination (and in this instance, for only one human game), in a measurable sense, is far larger than the real world. Walt Whitman (1819-1892) may not have known the celestial math, but he wasn’t exaggerating when he wrote Song of Myself.

“Do I contradict myself?

Very well then I contradict myself,

(I am large, I contain multitudes.)”

[Whitman W. Song of Myself. Section 51, 1892 version.]

Whitman imagined that he and each of us is unimaginably large, in imagination. This is sensory overload at its most. It is ironically, unimaginable, far beyond TMI.

Whether an incidentaloma discovered by ultrasonography, computer-assisted tomography, or magnetic resonance imaging, is important to the well-being of a person or is too much information (TMI) is one of the dilemmas of modern medicine. The quality and precision of ultrasound interrogation, reveal increasingly tiny anatomic details, anomalies, and imperfections that may cause great anxiety for patients, regularly driving parents of children with simple renal cysts to near-insanity with unnecessary worry. While technology seemed to promise humans better control of their lives, it may be just the opposite, whereby technology becomes the ruling agent. [Below: the promise of technology, Life Magazine, September 10, 1965.]

life_c2

 

Five.

An article and a book expand these considerations of gaze, ratiocination, and information. Roger Kneebone, in The Lancet, offered perspectives on “Looking and Seeing,” comparing a physician’s observational skills to those of an experienced entomologist, Erica McAlister at the Natural History Museum in London. The article begins with these resonating sentences, quoted with his permission:

“Medicine depends upon observation. Yet we are changing the way we look and that alters what we see. As a medical student, I was schooled according to a rigid mantra. Inspection, palpation, percussion, auscultation – always in that order … The aim, I think, was to ensure that we directed our attention to the person in front of us, that we didn’t jump to conclusions before assembling all the information we needed. That fell by the wayside as we turned into junior doctors. Nobody seemed interested in what we had seen or how we described it. Instead, it was all about blood tests, x-rays, scans – all about results.” [Kneebone R. “Looking and seeing.” The Lancet. 393:1091, 2019.]

Kneebone says it beautifully. The last word in his phrase could easily be data as well as results. The results becomes a proxy for the patient. The physicians of the next generation have learned excellent key-board skills, data collection, acronyms du jour, and navigation of electronic health records with drop-down menus, check-lists, and cut-and-paste artistry. The artful skills taught to me and Kneebone – inspection, palpation, percussion, and auscultation – seem rendered obsolete by data. One worries if the talents to navigate technology and its data come at the expense of the medical gaze, the medical sniff, and the ratiocination Edgar Allen Poe and Arthur Conan Doyle brought forth in their detectives. The model of the astute clinician is giving way to Watson, not Conan Doyle’s Watson, but IBM’s Watson.

Information or data, if you prefer, is a false deity. We may use data but should not worship it. Too many leaders say “show me the data,” believing that data will perfectly direct essential actions. Data should inform key decisions, of course, but data needs human wisdom for good decisions – using, tweaking, discarding, or reformulating data for human needs, not for the self-serving “needs” of algorithms. Self-learning algorithms can accomplish much, but can never replace human wisdom.

The book of relevance is Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, by Eric Topol, reviewed by Indra Joshi in The Lancet and I look forward to seeing if it convinces me in its promise. [Joshi I. “Waiting for Deep Medicine.” The Lancet. 393:1193-1194, 2019.]  The concern with “artificial intelligence” is its easy confusion with human wisdom, the wisdom of crowds that tends to bend toward truth and overarching human values. Self-learning algorithms that constitute AI are ultimately constructed by individuals with their own values, biases, and agendas. Furthermore, they are susceptible to intrusion and perversion. Finlayson et al warned of this recently: Adversarial attacks on medical machine learning, emerging vulnerabilities demand new conversations. [Finlayson SG, et al. Science. 363:1287–1289, 2019.]

 

Short story.

Truth is often stranger than fiction. Poe’s story in 1841 revealed the perpetrator of The Murders in the Rue Morgue was an orangutan smuggled to Paris by a sailor. The actual murders were unintentional, the escaped animal was frightened and responding as its genes, millions of years of environmental selection, prescribed. Most readers probably found that part of the story a bit outrageous, it didn’t quite make sense that a sailor could or would smuggle such an animal. But truth is often as strange or stranger than fiction: a recent report from the Associated Press of Russian tourist Andrei Zhestkov, discovered on the Indonesian resort island of Bali trying to smuggle a 2-year old drugged orangutan in a rattan basket to Russia on March 22. The smuggler also had seven live lizards in a suitcase. [Mike Ives. New York Times, March 25, 2019.]

Orangutan

 

Thanks for reading Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Spring

Matula Thoughts April 5, 2019

Calendar1

Spring considerations

20 minutes to read, two minutes to scan, one second to delete.

2341 words

Note of Passage

Mark C. McQuiggan, University of Michigan triple graduate, passed away last month leaving his beloved wife Carolyn (Brunk). Mark was the son of the late Dr. Mark R. McQuiggan and Dr. Catherine (Corbeille) McQuiggan, internists who had trained at the Mayo Clinic and worked together in an office in Detroit’s Fisher Building. Mark C. was born on May 15, 1933 and was 85 years old at the time of his death. He was thoroughly a Michigan Man with a BS from LS&A in 1954, an MD in 1958, and urology residency under Reed Nesbit, completed in 1964. Mark’s co-residents were Karl Schroeder and Dick Bourne, and other particular friends from residency were Clair and Clarice Cox and Dick and Jane Dorr.  Mark practiced urology with excellence and devotion in Southfield, Michigan, on the staff of North Detroit General Hospital and Ascension Providence Hospital. Mark and Carolyn were lovely and loyal presences at our yearly Nesbit Society Alumni Reunions. (Below: Mark in October, 2010, at the Nesbit Scientific Session.) Mark loved the University of Michigan, and Michigan Urology, along with Michigan athletics. Michigan Urology will miss Mark, who seemed to always have a smile and was a wonderful link to Michigan Urology’s past.

Urology at Michigan undergoes its own passage, this being the transition to Ganesh Palapattu as chair, who is already bringing exciting and substantive change to the department just around the fortuitous time of the Michigan Urology Centennial. He is continuing the weekly Urology What’s New aimed at departmental specifics along with this monthly set of Matula Thoughts on the first Fridays, and simultaneously available on the web site matulathoughts.org.

 

One. 

April brings spring, so welcome after a rough winter’s polar vortices reached down to our geography and innermost bodily cores. Flowering dogwoods, photographed last year (above), will return soon and that’s much of the attraction of photography – preservation of meaningful moments with fidelity to the momentary truth. We want to hold on to things we value as best we can and photography allows us to keep them, in a way, by replication. Words can also replicate those moments and truths with fidelity and beauty.

Last spring this column referred to Dr. William Carlos Williams and his book, Spring and All, a title mysterious in its promise. [Above: Williams and Ezra Pound at their last meeting, photographed by Richard Avedon in July 1958, Wikipedia.] The central piece in Williams’ collection, On the Road to the Contagious Hospital, speaks to facilities that that have faded away, the leprosaria, tuberculosis sanitaria, and other such places. New diseases and antibiotic-resistant resurgence of the old ones may resurrect those institutions. Leprosy, by the way, is not a disease of the past. The Lancet recently had a photoessay “Picturing health new face of leprosy.” The authors noted: “… leprosy impairs and society disables.”  [Kumar A, Lambert S, Lockwood DNJ. The Lancet, 393:629-638, 2019.]

The University of Michigan once had its own contagious hospital after the citizens in Ann Arbor in 1914 voted for a bond issue of $25,000 for an isolation hospital to be maintained by the university. [Below: UM Contagious Disease Hospital, courtesy Bentley Library.] It was placed on a ridge behind the Catherine Street Hospital and looked over the Huron River. Horace Davenport’s book (Not Just Any Medical School, 1999) tells how in the first year the 24-bed hospital housed patients with chicken pox, diphtheria, necrotizing ulcerative gingivitis (Vincent’s angina), pneumonia, tuberculosis (TB), and whooping cough. [Davenport HW. Not Just Any Medical School. University of Michigan Press. 1999.]

 

Two.

Photography, as a neologism meaning drawing by light, may have had a number of separate origins between 1834 and 1839. Previous methods to capture images by means of cameras obscura or shadow images on silver nitrate-treated papers were novelties, but didn’t scale up in terms of utility, until Louis Daguerre announced his sensational process on January 7, 1839. The rest is the history of the Kodak moment, motion pictures, Polaroids, and now the cell phone camera with its albums of thousands of pictures and videos.

Anesthesia, in contrast to photography, had a specific origin in time, place, and originator. Anesthesia was the neologism of Oliver Wendell Holmes in Boston, 1846. Just as photography was coming of age, medical practitioners were starting to bring science and new technology to their art. Large metropolitan hospitals, notably the Napoleonic legacies in France, afforded large numbers of patients that inquisitive physicians studied and compared. Evolving tools of measurement and investigation allowed new clinical skills and a slowly growing sense of hygiene would bring a greater level of safety to medical care.

Professor Charles-Alexandre Louis (1787-1872) in Paris at the Pitié-Salpêtrière was among the best of these physicians and his comparison of patients with pulmonary TB who were treated with leeches against those untreated patients was one of the earliest clinical trials. Young people from around the world came to Paris for weeks, months, or years to watch Louis at work. He stressed the idea of critical clinical observation (including the medical gaze), measurement, and analysis to improve understanding of disease and therapy, forming a Society of Clinical Observation that many young American trainees joined.

The idea of clinical material as the milieu for medical education and the improvement of health care through careful observation, inquiry, and research, received as great a boost from Louis as anyone. The medical gaze went beyond a quick visual glance. Deep inspection by an experienced physician was something new, a gaze that would discover clues to a diagnosis, understanding of co-morbidities, and other relevant facts to the case, the story, and the truth of a clinical situation.

The medical gaze, like the photograph, was novel and they complemented each other. Photography became a teaching and documentary tool. The informed gaze discovered a condition, an attitude, or a moment that the photograph could replicate and preserve. The medical gaze also inspired a new genre in literature – bringing the idea of astute medical discovery by observation, listening, and reasoning to crime solving.

One wonders if the medical gaze, once a desirable clinical skill, has now been eliminated by modern imaging tests, laboratory studies, biomarkers, and check lists? This begs the question whether or not tomorrow’s masters of those technologies and processes will quickly succumb to nonhuman purveyors of “artificial intelligence”?

 

Three.

The Murders in the Rue Morgue, Edgar Allen Poe’s famous short story in 1841, initiated a new genre of crime literature and the clever reasoning, Poe called “ratiocination,” necessary to solve crimes. [Poe 1809-1849, above] Curiously, Poe’s story included a brief speculation on uroscopic clues, specifically the odor of urine.

This scientific crime solver genre continues to gather cultural momentum. The picture above, made in the last year of Poe’s life, is the “Annie” daguerreotype, the best known of the eight known Poe daguerreotypes and named for Mrs. Annie Richmond of Lowell, Massachusetts who commissioned and owned the picture. Poe was just a little ahead of his time with ratiocination, his take on the medical gaze, where careful observation and trained reasoning could discover the truth of a situation. Over the next decades up to the fin de siècle a scientific corpus of knowledge, bringing new technology, would expand the medical gaze into a powerful capacity to produce data and evidence for both health care and criminal investigation.

Future detective author Arthur Conan Doyle (1859-1930) was barely ten years old when Preston B. Rose started teaching Ann Arbor medical students urinalysis and scientific methods of forensic investigation in the Chemical Laboratory just behind the University of Michigan Medical School. Only 17 years later, as a 27-year old ophthalmologist with a struggling practice, Conan Doyle created a powerful blend of ratiocination and scientific analysis in the intellectual superhero, Sherlock Holmes. The detective was modeled on a real-life medical role-model of Doyle when he was a medical student and the name Doyle selected coincided with the real-life medical superhero Oliver Wendell Holmes, one of the most prominent Americans Abroad, who studied with Louis in Paris, as explained in David McCullough’s book. After return to Boston, Holmes presented one of the first convincing hypotheses for the germ theory to explain puerperal fever. [Below: Sir Arthur Ignatius Conan Doyle by English photographer Herbert Rose Barraud. Carbon print on card mount. Courtesy of the National Portrait Gallery, London.]

Doyle SS

 

Four.

Holmes embraced the new technology of photography, writing essays about it, making his own pictures, inventing a stereoscopic camera, and studying human ambulation with it. In the June issue of The Atlantic Magazine in 1859 Holmes commented on the improbability of the technology of capturing an actual moment in time totally on a single surface:

“This is just what the Daguerreotype has done. It has fixed the most fleeting of our illusions, that which the apostle and the philosopher and the poet have alike used as the type of instability and unreality. The photograph has completed the triumph, by making a sheet of paper reflect images like a mirror and hold them as a picture.”

It is a universal truth that pictures tell stories more immediately than words, and we humans have been practicing this art since cave-dwelling days, inspired by beauty in the natural world, fantasies, or unnatural horrors. Photography offers realistic images of faces, scenes, or situations, and complements the older visual arts of drawing or painting.

Earlier, in the inaugural Atlantic Monthly (above) Holmes had written:

“The next European war will send us stereographs of battles. It is asserted that a bursting shell can be photographed… We are looking into stereoscopes as pretty toys, and wondering over the photograph as a charming novelty; but before another generation has passed away, it will be recognized that a new epoch in the history of human progress dates from the time when He who

Never but in uncreated light

Dwelt from eternity –

Took a pencil of fire from the hand of the ‘angel standing in the sun,’ and placed it in the hands of a mortal.”

[“The stereoscope and the stereograph,” Atlantic Monthly, November, 1857.]

 

Five.

Guernica. Pablo Picasso (1881-1973) while living in Paris was commissioned by the Spanish Republican Government to make a work in response to the destruction of Guernica. This  Basque town in northern Spain was bombed for two hours by Nazi Germany and Italian warplanes in their support of Spanish nationalists on 26 April 1937. [Above: Picasso working on the mural. Wikipedia.] The town was at a major crossroad 10 kilometers from the front lines between the Republican retreat and Nationalist advance to Bilbao. The target was a minor factory for war materials outside of town. The bombers missed the factory, but destroyed the town.

Picasso completed the large oil painting on canvas in June, 1937, after 35 days of work. The specific disputes of the Republicans and Nationalists, and the justifications of their supporters and suppliers are nowhere evident in the mural, only the grotesque mangled forms and anguished expressions of the victims. Guernica may be Picasso’s greatest work and one of mankind’s iconic images of the horror of war. The event itself was miniscule in the grand scale of 20th century conflict, but Picasso made it a transcendent moment for humanity.

No single painting, photograph, or narrative can capture the full and terrible story of Guernica, although together they give a fuller sense of the horror than any one work alone. [Above: Museo Reina Sofia, Madrid, Spain. ©Picasso. Below: ruined Guernica. German Federal Archives.]

Guernica, Ruinen

Picasso had commissioned three full-size tapestry reproductions of the work by Jacqueline de la Baume Durrbach and her husband René in 1955, weavers in Southern France. Nelson Rockefeller purchased one of these and it hangs on loan in the United Nations at the entrance to the Security Council room. A blue curtain strategically covered Guernica for televised press conferences of Colin Powell and John Negroponte on 5 February 2003. [Kennedy M. “Picasso tapestry of Guernica heads to UK.” London: The Guardian, 26 January 2009.] Picasso entrusted Guernica to the Museum of Modern Art in New York, pending re-establishment of liberty and democracy in Spain. After Spain became a democratic constitutional monarchy in 1978 the painting was ceded to Spain in 1981, although not without dissent that the ruling system was still not quite the republic stipulated by the artist in his will.

 

Short bits.

Morbidity and Mortality (M&M) conferences, discussed here last month, brought M&M candy to mind. The story goes that the Spanish Civil War inspired Forrest Mars, Sr. to create an American version of the British confection Smarties. Mars was working in England in the candy business at that time, estranged from his father, Frank Mars of Mars candy fame. Forrest had created the Mars Bar in Slough in 1932 and was looking for another product. Rowntree’s of York, maker of Chocolate Beans since 1882, had recently tweaked the name to Milk Chocolate Beans in 1937, and changed it to Smarties the following year. These oblate spheroids were sold in cylindrical cardboard tubes, with a colorful lid that contained a random alphabet letter, designed to encourage children to learn. The chocolate center was protected by a shell of hardened sugar syrup to prevent melting, a convenience enjoyed by soldiers in the Spanish Civil War.

The Spanish Civil War (17 July 1936 – 1 April 1939) engendered strong international sympathies, involving anarchists, communists, nationalists, aristocratic groups, and religious factions, although largely became viewed as a contest between democracy and fascism. British volunteers, likely including George Orwell, carried Milk Chocolate Beans and Smarties into battles and Forrest Mars might have noticed. Just as likely one of his children brought some home.

Returning to the U.S. and working with Bruce Murrie, son of Hershey Chocolate’s president, Mars developed their button-shaped variant, patented it on 3 March 1941, and began manufacture that year in New Jersey. M&M derived from Mars and Murrie, with a small “m” stamped on each button. The first big customer was the U.S. Army and during WWII M&Ms were sold exclusively to the military. “Melts in your mouth, not in your hand,” was first used as a tagline in 1949. Peanut M&Ms were introduced in 1954, and the rest is history.

Thanks for reading Matula Thoughts

David A. Bloom, M.D.

University of Michigan, Department of Urology, Ann Arbor

 

 

Sun rise 2019

Matula Thoughts Jan 4, 2019

Sun rise 2019
3734 words

 

Periodic re-explanation. This column, Matula Thoughts, recalls ancient uroscopy flasks called matulas, used for centuries to examine urine for clues to illness. People want to know “what comes next,” a question, explicit or unspoken, dominating most conversations in medical practice: “can it be fixed and what will happen to me?” Remedy and prognosis mattered more than diagnosis in ancient days, when technology and verifiable medical knowledge were sparse, and understanding pathophysiology (using today’s terms) was not as useful to a patient as remedy and prognosis. Direct examination of urine, particularly for color change, was one of the few early tools of practitioners and the matula was the dominant symbol of the medical profession for over 600 years in western art, until Laennec invented the stethoscope in 1816.

As a monthly collection of thoughts, relevant and random, from a senior genitourinary surgeon, the title seems appropriate. This electronic column began nearly 20 years ago in Allen Lichter’s dean’s office as a weekly email called What’s New. After returning full time to Jim Montie’s Urology Department in 2007, we continued What’s New as a weekly communication, published every Friday by varying members of our department, except for the first Friday of each month when I claimed the electronic podium. A parallel version began 5 years ago on the website MatulaThoughts.org. Happily, the Department of Urology will soon have a new chair with forms of communication to better match the times and people of the next decade. Nevertheless, this monthly habit will continue at MatulaThoughts.org reflecting personal observations, relevant and irrelevant, and events related to Michigan Medicine and the Department of Urology. [Above: Sun face on ceiling fresco, church of Saint Jean-Baptiste de Larbey, Southwestern France. 1610. Wikipedia. Below: variant of Nesbit log by Julian Wan.]

 

One.

Imagine just 100 years ago how different things were for our predecessors at the University of Michigan Medical School: Americans were recovering from WWI and the first two deadly waves of the 1918 influenza epidemic; Woodrow Wilson was US president, having been Princeton president when he was offered the Michigan job ten years earlier; women couldn’t vote and any adult could drink alcohol on this day in 1919, but by the end of the year women’s suffrage was secured in the 19th Amendment and prohibition came with the 20th Amendment; socialist and communist parties were on the rise; anarchists were preparing for spring bombings; and racial tensions festered nationally. Meanwhile, the University of Michigan carried on with its work at the Medical School and University Hospital, as life went on in Ann Arbor. [Above: Approaching New Year’s Eve, December, 2018, Liberty & Ashley, Ann Arbor.]

The University in 1919, already more than a century old as an organization and in Ann Arbor for around 80 years, was amidst a building binge under President Hutchins with the new Union, Art Museum, Hill Auditorium, and other defining structures. The 60-year old Medical School, which had looked quite good to Flexner on his visit in 1909, had since fallen behind its peers in terms of facilities. The hospital was badly out of date well before the war and replacement was further delayed by the national emergency. The practice of urology at UM was a little more than a single faculty effort in a surgery department consisting of a handful of other individuals.

Late in 1919, Medical School dean Victor Vaughan recruited Boston urologist Hugh Cabot, who would engineer 11 years of change bringing the Medical School back to the top of medical education internationally and at the pinnacle of state-of-the-art clinical practice for the first time. Academic urology in Ann Arbor surely began with Cabot.

 

 

Two.

Pundits and ordinary folk made predictions and resolutions when the sun rose on 1919 and we repeated these customs three days ago. Events will happen and paradigms will surely change over the next 12 months, but the only solid predictions this posting will offer for 2019 are: a new chair will begin stewardship of this fine Department of Urology sometime soon and we will celebrate the Michigan Urology Centennial later in the year. Other than those predictions, the rest is noise (to borrow the title of the book on 20th century music by Alex Ross). Sunrise each new day or year brings uncertainty and new possibilities. Predict and resolve whatever you wish, paradigm changes are usually outside your control, although the ability to recognize their inflection points is a useful gift. [Below: Encyclopaedia Biblica, 1903. Public domain.]

The centrality of the Sun to life is a fundamental feature of biology and logically a universal symbol in human civilizations. The 14th century BC image of pharaoh Akhenaten (Amenhotep IV) worshipping sun god Ra, in form of Aten, shows a partial solar disc with rays ending in little hands. Curiously, Akhnaten (1983) was one of three biographical operas written by American composer Philip Glass, the other two being Einstein on the Beach (1976) and Satyagragha (in 1979, about Mahatma Gandhi).
Inevitably, an Anthropocene imprint was added to the sun, seen in the introductory figure from Larbey and much earlier in a 4th century BC marble relief of sun god Helios driving his chariot at the Temple of Athena in Troy. [Below: Pergamon Museum, Berlin.]

The man-in-the-moon, a whimsical anthropomorphic imagination, when combined with a solar face suggests the ancient Asian complementary opposites yin and yang. [Below top: Amiens, Bibliothèques d’Amiens Métropole, manuscrit Lescalopier (Fourth Day of Creation) c. 1200. Wikipedia. Bottom: yin and yang.]

 

Janus, Roman god of beginnings, looked to both the future and the past, presiding over transitions such as war and peace,  and might be viewed as a symbol of paradigm shifts in modern times . [Below: Janus, Vatican Museum.]

Solar symbols, seen on some national flags, are ubiquitous in the Happy Face, the mother and father of all emoji, designed by commercial artist Harvey Ball in 1963. Charles Kuralt’s Sunday Morning show, launched by CBS News on January 28, 1979, continues to employ a solar disk theme throughout 40 years of reiteration by Charles Osgood and Jane Pauley, remaining a pinnacle of news and civilized commentary as each episode rolls through a set of beautifully curated solar symbols. [Below: Sunday Morning (top) & Authentic Worcester Smiley (bottom).]

 

Three.

Isaac Newton’s big paradigm shifts began inauspiciously when he was born this day in 1643. His birth date in the old-style calendar was 25 December 1642, but Gregorian conversion brings his birthday to today in the modern calendar and solar year. Bad luck shaped him from the start; father died three months before he was born and mother commented that Isaac, ar birth, could fit inside a quart mug (Wikipedia). Mother remarried, but young Isaac, unhappy at home and bullied at school, reacted by focusing on his studies, becoming a top student at Trinity College in Cambridge. Apples, gravity, planetary motion, and mathematics come to mind at first with Newton’s name, which is also celebrated in the term for a unit of force.

Newton’s color theory was another product of his astonishing ability to think about the world and find clarity about how things work. Countless people before him had seen white light refract through glass prisms into the colors of the visible spectrum and everyone sees rainbows. Yet only Newton carried those observations into a theory of color, described in a book he wrote at 71 years of age in 1704: Opticks: or, a Treatise of the Reflections, Refractions, Inflexions, and Colours of Light. [Above: double Alaska rainbow. Eric Rolph. Below: Color wheel of Goethe. Wikipedia.]

Color theory continued to attract great minds, including German polymath Johann Wolfgang von Goethe (1749-1832) and Scottish scientist James Maxwell (1831-1879) whose differential equations in 1865 explained the electromagnetic spectrum. [Below, User:penubag, Wikipedia.]

An early Apple Computer symbol (above) was perhaps an intentional play on Newton himself and Adobe’s color disk (below) fragments color into infinitesimal gradients of hue.

 

Four.

Urine may not be a window to the soul, but it’s a useful indicator of disease through color, sediment, or odor. Red is an obvious hallmark of trouble, whether renal trauma, urinary stone, kidney cancer, bladder cancer, infection, BPH, structural anomaly, metabolic dysfunction, rhabdomyolysis, or genetic mutations. Ancient uroscopists expanded color change into fanciful imaginations and medieval uroscopy charts offered wild speculations of what color, sediment, consistency, smell, and taste of urine might portend in terms of prognosis. [Below: uroscopy clinic. Hortus Sanitatis. 1491, Mainz. Courtesy Dick Wolfe, Countway Library.]

The paradigm shift from uroscopy to urology occurred over two centuries replacing sensory examination of urine by eye, nose, and occasionally tongue, with microscopy and chemical analysis. Nevertheless, persistent uroscopic fortune-tellers claimed legitimacy even in the face of emerging scientific reason. Thomas Brian’s book in 1637, The Pisse Prophet, is a classic example of rational attempts to debunk dogma and fraud.[Below: Wellcome Library, 1655 copy.]

The metabolic dysfunction porphyria (named for purple urine) affected Scottish physician, Archie Cochrane, born 110 years ago in 1909 on January 12, and the prime advocate in modern times for evidence-based health care. Later this month Guilia Lane, our FPMRS fellow, will educate us on Cochrane in What’s New. [Below: normal urine sample on left and porphyria sample on right.]

This sample below from my clinic a few years ago was oddly green, but I failed to make note of the cause. Color still matters in modern urinalysis although, since matulas gave way to microscopy and chemical analysis, physicians rarely demand to view urine themselves before it heads to a machine or laboratory.

Macroscopic uroscopy gave way nearly completely to modern urine investigation with specific gravity measurement, chemical analysis, microscopic exam of spun sediment, bacteriologic culture, antibiotic sensitivity testing, and who knows what will come next. Twentieth century urinalysis was a cornerstone of urologic practice when it was unimaginable for a patient to leave the office of a good urologist without submitting a urine for examination. Hinman’s Eight Steps to Presumptive Diagnosis constituted the basis of urologic practice, at his start in San Francisco in 1920 as the first trained urologist west of the Mississippi: history, general examination, abdominal and external genital exam, urinalysis including a stained smear, prostate exam, plain x-ray, phenolsulfonephthalein test (PSP), and residual urine. [Bloom DA, Hinman F Jr. Frank Hinman, Sr: a first generation urologist. Urology. 61:876-881, 2003.] Color and other sensory inspection still matter and while details have changed, urology is diminished somewhat when its practitioners no longer personally inspect urine grossly and microscopically, favoring instead automated readout from machine or lab.

 

Five.

The story of urology at the University of Michigan was last told 20 years ago just after the Urology Section in the Medical School Department of Surgery emerged as a full-fledged department alongside its sibling disciplines of Neurosurgery and Orthopaedic Surgery. Much happened in the next 20 years to justify a new rendition of the story and additionally much more has been learned about the earlier years. The new book should coincide with the Michigan Urology Centennial, beginning later this year. Urology is a microcosm of modern specialized health care, but its roots are also of particular interest as the first designated medical specialty in Hippocratic times and the stories since then of the discoverers, progression of skills, and innovations that led to 19th century genitourinary practice and 20th century urology should be retold and interpreted for each new generation.

No story is ever complete, in its recollections of the past, because only partial relevant knowledge is known to any author and myriad other details of the cultural and physical soups surrounding those facts are mostly lost to historical recollection. Lucky historians may find, reconstruct, resuscitate, or recover useful details, but all stories are largely narratives of imagination and facts, whether true facts or otherwise, in the words of the late urological scientist, Don Coffey. Stories, even as particular as one of an academic urology unit, are enriched by the context of its people, events, and circumstances. For example, it’s inconceivable to consider urology at Michigan without understanding Moses Gunn, and any appreciation of Gunn requires the context of the Civil War. In that sense, the Michigan urology story aims to be rich in context.

 

Six.

The bicentennial edition of Howard Peckham’s sesquicentennial work, The Making of the University of Michigan, by Margaret and Nicholas Steneck is indispensable to understanding this institution. The Stenecks proposed, metaphorically, that this university began with a single strand that represented the foundational aim of the university to disseminate knowledge and embracing education at all levels. This strand thickened over time and became joined by a second strand, turning around the first one, the new strand representing knowledge itself, that must be interpreted, renewed, created, and disseminated through explorations, criticism, research, and invention. The Stenecks identified yet another part of the braid.

“Now there is a third strand wound with the other two. The University touches more than just its young students and faculty. It gives services to the State that help maintain it; it aids citizens who never enroll. These services began when its hospitals received perplexing cases from all over the State. It continued with the upgrading of high schools, the testing of municipal water supplies, with experiments in reforestation, testing programs for state highways. It supplied reading lists for club programs, lecture series for enlightenment, and musical concerts for entertainment. It expanded to research contracts for Michigan industries, development of new products for manufacture in Michigan, seminars for business executives, realtors and assessors, state college presidents, and refresher demonstrations for physicians and dentists. It provided radio and TV educational programs for all. Teaching–research-and service. These are the warp and woof of the University today.” [Peckham HH. The Making of the University of Michigan. 1817-1992. Edited and updated by ML Steneck and NH Steneck. University of Michigan. Ann Arbor. 1967, 1994. p. 1-2.]

A better term for “service thread” is that of public goods, and today those public goods extend far beyond the state of Michigan to the world at large. Universities, since the Middle Ages, have been the single entity in human society to attend consistently and dutifully, albeit imperfectly, to the human and planetary future. In the past few centuries the university, or the Academy as some call it, has extended from small Ivory Towers that educate a particular narrow subset of learners, to complex Multiversities with broader aims such as the Stenecks listed.

 

Seven.

Mission homeostasis. The University of Michigan entered the 20th century with a more complex, but clearer iteration of an academic medical center than it displayed at its start when medical education was the sole basis for its existence. The Chemical Laboratory in 1856 introduced the service of chemical analysis to medical education, clinical practice, and scientific discovery. A more complete linkage of medical education to clinical practice came with Michigan’s first university hospital in 1869 and by its third iteration in 1891 the triple mission of an academic medical center was fully in place, although confusion over priorities played out in such disputes as moving the medical school closer to large urban populations and hospitals, compensation of clinical faculty, and criteria for academic promotion.

Mission balance continued to confuse faculty and perplex leadership for that next century and into the present one. History brings some clarity to the matter: the University of Michigan Medical School began with an educational mission of training the next generation of physicians, research followed quickly initially to refine biochemistry in the service of the public, and clinical care was recognized as the necessary milieu for medical education and research. Among these three parts of the conjoined mission, clinical care is the moral epicenter, trumping any other part of the mission at any moment. Furthermore clinical care, a matter of complex intellectual teams, is the financial engine that currently underpins the other missions. Any great academic medical center must be first and foremost a state-of-the-art health care system that not only delivers excellent patient-centric service, but also studies and improves its systems of care and technologies along with its many scholarly and clinical disciplines. Clinical teams are the essential center and most important deliverable of academic medical centers. [Above: scribe’s heart measured against “feather of truth.” Book of the Dead, c. 1,265 BC. National Geographic, Ancient Egyptians. May 2009.]

 

Eight.

No Property in Man. January 15, 1929, the birthday of Martin Luther King, Jr., is celebrated later this month for his role in the slow, halting, and sometimes retreating movement towards universal human rights, a struggle that remains a very incomplete paradigm shift worldwide. [Above: MLK 1964.] Extending Mahatma Gandhi’s methodology of nonviolence and civil disobedience, King fought inequality through resistance that was nonviolent on his side of the bridge to change laws, public sensibility, and hearts and minds. Martin Luther King Day is celebrated around the time of Dr. King’s birthday, January 15, but the specific day this year will be January 21 according to the Uniform Monday Holiday Act. Michigan Representative John Conyers along with US Senator Edward Brook (MA) offered the first bill in Congress to honor King, but it fell short of passage by a few votes in 1979. In 1983, President Reagan signed the final bill to establish the day of remembrance, which commenced in 1986, also establishing a federal commission to oversee observance of the holiday. In 1989 President George HW Bush made Coretta Scott King a lifetime member of the commission. Toronto, Canada, Hiroshima, Japan, and Wassenaar, Netherlands also honor Dr. King with public observances.

We don’t close clinics, operating rooms, or phone lines for that day at Michigan (that would hardly have been in the spirit of Dr. King, anyway), but the occasion offers a time for reflection, study, relevant academic talks, and renewed efforts toward the unfulfilled paradigm shift to universal human rights. A good friend and Americana scholar, Jim Beuche, recommended a book called No Property in Man, by Sean Wilentz. In the spirit of this month, this is a “must-read” for 2019. Wilentz explains the issue starting at the Federal Convention (U.S. “Constitutional Convention”) in 1787.

“Descriptions of the Constitution as proslavery have misconstrued critical debates inside the convention. They have slighted the anti-slavery impulses generated by the American Revolution, to which the delegates, for better or for worse, paid heed. They have missed the crucial subtlety, which is this: although the framers agreed to compromises over slavery that blunted antislavery hopes and augmented the slaveholders’ power, they also deliberately excluded any validation of property in man.” [Wilentz. No Property in Man. Harvard University Press, 2018.]

Many forces assembled to abolish slavery in America, but Wilentz argues that the United States Constitution, the Republican Party (“an antislavery mass organization unprecedented in world history”), Proclamation 95 (Lincoln’s Emancipation Proclamation), and the 13th Amendment, legally abolished any legitimacy of the notion of “property in man” in America. [Below: page one of the five-page Emancipation Proclamation. National Archives.]

At President Kennedy’s suggestion, King led an effort to draft a Second Emancipation Proclamation, that would have outlawed segregation and expanded equality, but Kennedy’s Executive Order 11063 fell short of the draft. Lyndon Johnson’s Civil Rights Act of 1964, fulfilled more of King’s aspiration. That year King won the Nobel Peace Prize at age 35. He was assassinated in 1968 at age 39.

 

Nine.

Harvey Ball (1921-2001) designed the Happy Face to repair a decline in morale after the bumpy merger of two insurance companies. How effective the ideogram was in that instance is not clear, but Ball earned $45 for it and never applied for trademark or copyright. He never voiced regret for giving his symbol to the public, even after it became a universal symbol. Ball was born and raised in Worcester, Massachusetts, served in the Pacific Theater of WWII with a Bronze Star for heroism at Okinawa, started his own advertising company in his home town in 1959. One day, in 1963, he drew Smiley.

 

As a matter of law, copyright goes back to 1709 and the Statute of Queen Anne of Britain, the last monarch of the House of Stuart and the same Anne portrayed in the current film, The Favourite. Another current film, Mary Queen of Scots, portrays the start of the House of Stuart two centuries earlier, with the conception and birth of James, later first Stuart and first king to preside over England and Scotland.

The U.S. Constitution in 1787 includes a Copyright Clause (Article 1, Section 8), recently updated with the Copyright Act of 1976 and the Sonny Bono Copyright Term Extension Act of 1998, also called the “Mickey Mouse Protection Act” [Above: Queen Anne’s Statute. Below: Bell’s graph of US Copyright law expansion. “©1999-2008 Tom W. Bell. All rights reserved. Fully attributed noncommercial use of this document permitted if accompanied by this paragraph.” Wikipedia.]

Three days ago (Jan 1, 2019), according to U.S. copyright laws, all works published in 1923 entered the public domain. Sonny’s name was likely linked more to his music than his love of 1923 literature. (Wikipedia.) Works published then were to have entered the public domain in 1999, but were granted postponement by 20 years when Congress extended their copyright length with the Bono Act. Willa Cather’s A Lost Lady, Agatha Christie’s The Murder of the Links, Joseph Conrad’s, The Rover, Kahlil Gibran’s The Prophet, Marcel Proust’s The Prisoner (vol. 5 of In Search of Lost Time), William Carlos Williams’s The Great American Novel, and Virginia Wolfe’s Mrs. Dalloway in Bond Street were so reprieved.

[Above: copyright applied. Below: public domain.]

 

Ten.

Matula Thoughts analytics, 2018. We have no sense of the readership of the monthly What’s New delivered by email, but the web version, MatulaThoughts.org had 3454 views last year compared 3173 views in 2017. Viewers came from 89 countries, ranging from a few viewers in 35 countries, to 54 in Germany, 70 in the U.K., 87 in Canada, and 2578 in the US. Most views are cursory, but we enjoy hearing back directly from periodic careful readers who challenge our facts and alert us to errors.

[Above: analytics 2018.]
New Year 2019 began on a Tuesday and a short work week ends today for most people, but health care is a 24/7 business and by necessity we will offer more scheduled afterhours and weekend services at Michigan Medicine Urology, even though we have been doing so formally and informally for years. It is curious that most calendars begin each week on Sunday, although for most people that day is the end of the week and weekend, with the next week beginning at sunrise on Monday.

The 1902 fantasy film, Le Voyage dans la Lune, by Georges Méliés, shows an oversize spacecraft planted in the right lunar eye. We don’t have to travel 240,000 miles to stick it to a heavenly body, because Homo sapiens is doing this well enough right here at home on Earth, but possibly 2019 will be a turning point for planetary stewardship.

[Above: Schedel’s World History or Nuremburg Chronicle, 1493. Below: Earthrise, December 24, 1968. Apollo 8 astronaut William Anders.]

 

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

December

Matula Thoughts Dec 7, 2018

3930 words

 

One.

Tiny Tim Cratchit and Ebenezer Scrooge come to mind in December when seasonal good cheer expands the possibilities of latent human kindness, turning some Scrooges into their better selves, exemplified by Charles Dickens’ 1843 tale. The author played the story well, for who can’t empathize with Tiny Tim, whose disability reminds us of the Americans with Disabilities Act (ADA), signed by GHW Bush in 1990? The late president said, at the signing, that he was glad to help take down “that shameful wall of exclusion,” little knowing that the ADA would help his own access to public spaces during his wheelchair years 25 years later. [Above, upper Liberty Street, cold afternoon. Below: Tiny Tim & Bob Cratchit. Fred Barnard illustration for 1870 ed.]

We don’t need Marley’s ghost, to exercise our philanthropic nature this month. [Above: Scrooge enlightened by Marley’s ghost. John Leech Illustration in A Christmas Carol, Chapman & Hall, London. 1843. British Library.]  Tax advantages, to a dwindling extent, also enter the philanthropic calculus as people evaluate well-constructed requests for their dollars. Pleas for out-of-pocket “spare change” from panhandlers is a complex matter, sometimes linked to homelessness, but just as likely separate and multifactorial. Like most human enterprises, it grows if supported. Solicitations on the streets are often more a business rather than a solution to hunger, homelessness, poverty, mental illness, or substance abuse. Panhandling makes downtown spaces a little uncomfortable, and although handing over a buck provides momentary satisfaction, it doesn’t further the greater good of the truly needy or the public.

The community of Ann Arbor has come together for excellent programs such as the Delonis Center, Ozone House, Alpha House, Salvation Army Shelter, Dawn Farms, Home of New Vision, Packard Clinic, Hope Clinic, and Neutral Zone, but these don’t fill all the needs of homeless or otherwise at-risk people. Spare change gifting has a doubly negative effect: it encourages the business of panhandling, and it relieves guilt of panhandled individuals, who preferably could expend constructive efforts on durable solutions to the causes and needs of the people who seek help. Shelters, food banks, health care, public safety, job programs, education, and low-income housing, need political support, public policy solutions, volunteerism, and philanthropy. If you encounter a panhandler and feel guilty, consider pointing out a nearby shelter or offering a nutrition bar.  [Below: Sidney Paget illustration, The Man with the Twisted Lip. Arthur Conan Doyle, 1981.]

 

Two.

Galens Medical Society, founded in Ann Arbor in 1914 as a liaison between students and faculty, began charitable Tag Days in 1927 and solicits funds on the streets the first weekend in December.  Medical school became costly in the 20th century and in the 1930s Galens established scholarships and a loan fund. Galens now targets its funds to children’s needs in Washtenaw County.

Salvation Army kettles usually decorate December streets, although I saw few this past weekend. This evangelical church began in 1865, when Methodist circuit-preacher William Booth and his wife sermonized at the notorious Blind Beggar tavern in East London. The Salvation Army is best known for its crusade against alcoholism, as portrayed in George Bernard Shaw’s 1907 play, Major Barbara. The organization uses military titles, the CEO is referred to as General, and the kettles began in 1891 when Salvation Army Captain Joseph McFee placed one at San Francisco’s Market Street Ferry Landing to collect Christmas dinner money for impoverished members of the community. Disaster relief is another function of the organization.

Homelessness also applies to pets, and the Huron Valley Humane Society is another consideration for your generosity. Philanthropy, or anthrophilia, is a restricted form of biophilia, a term embraced by E.O. Wilson, who wrote:

“… to explore and affiliate with life is a deep and complicated process in mental development. To an extent still undervalued in philosophy and religion, our existence depends upon this propensity, our spirit is woven from it, hope rises on its current.

There is more. Modern biology has produced a genuinely new way of looking at the world that is incidentally congenial to the inner direction of biophilia. In other words, instinct is in this rare instance aligned with reason. The conclusion I draw is optimistic: to the degree that we come to understand other organisms, we will place a greater value on them, and on ourselves.”  [Wilson EO. Biophilia. Harvard University Press, 1984. p. 1-2.]

 

Three.

The urology chair will transition next year as the Michigan Urology Centennial approaches, and the first part of the Michigan Urology story should be in print at next year’s Nesbit Society meeting, October 3-5, 2019. The early history of UM reveals the foundational role of philanthropy, beginning as a partnership of community, state, and generous people who wanted to create something worthy and great in Ann Arbor. The same was true for its first hospital. With declining support from local and state government, philanthropy becomes mission-critical, evidenced by the recent University of Michigan campaign with $1.5 billion dollars for Michigan Medicine, celebrated last month at the North Campus Research Center. [Below: Becky and Randy Tisch flanked by Harry and Natalie Mobley.]

Endowments and endowed professorships impact our department greatly. The Babcock Fund jump started dozens of research projects and bolstered our residency and fellowships for 80 years. The Lapides endowment affected my career, Stuart Wolf’s small renal mass data set changed the worldwide approach to kidney cancer with the Brain and Mary Campbell family gift, and the professorship from George Valassis very positively helped the careers and academic work of Jim Montie, Dave Wood, Ganesh Palapattu, and Khaled Hafez. The Brandon survivorship gifts have been of inestimable value to hundreds of patients and the career of Professor Daniela Wittmann. The Chang, Nesbit, McGuire, and Moyad professorships followed, as did the Complementary/Alternative Medicine Program under Mark Moyad, initiated by Phil Jenkins, Bob Thompson, and Josh Pokempner. We are still short by ten of the need to match professorships to the expanding ranks of senior faculty.  Endowed professorships will be the essential structural elements for any great clinical department of the future.

Jerry May, UM Vice President of Development, steps down after 30 years of bountiful leadership (above, during a tough day in Columbus). Eric Barritt (below with John Copeland) has effectively led Michigan Medicine development for four years and we have enjoyed Vince Cavataio as urology’s development officer over the past two years. Endowment-building requires diligent work with a good measure of luck. In this sense, it is both stoichiometric (assembly with the right elements and proportions) and stochastic (random).

[Below: at Nesbit tailgate Vince and Tonya McCoy.]

 

Four.

Moral dilemmas of health care were explored in another Shaw play, The Doctor’s Dilemma, first produced November 20, 1906. Its Preface provides an even sharper dissection of the medical profession than the play itself. Parsing of scarce medical resources was exemplified in the story by a new cure for tuberculosis (TB) that its physician-inventor, Sir Colenso Ridgeon, could only provide to ten patients at a time. From his first group of 50 TB patients Ridgeon had to select ten “most worthy” of cure. Personal foibles added to the doctor’s dilemma when an irresistable young woman asks him to cure her dissolute husband. Around the same time a poor but noble colleague of Ridgeon’s with TB also appeals for help. Suddenly, Sir Colenso has 52 patients in need, but still only resources for ten. His other dilemma was the timeless conflict between medicine as a profession and a personal business.

Shaw modeled Ridgeon on Sir Almroth Wright (1861-1947), British bacteriologist and immunologist (below) who was one of the first to predict that antibiotics would create resistant bacteria, an idea Shaw used in his 1932 comedy, Too Good to Be True. Wright was opposed to women’s suffrage and their entry into professions, writing a book in 1913, The Unexpurgated Case Against Women Suffrage. Wright’s contrary nature probably made him suitable for Shavian friendship and earned him the names “Almroth Wrong” and “Sir Almost Right.” Wright would have raised his eyebrows had he visited Ann Arbor when the Galens Society began and found women included in the Michigan medical school class since 1871.

An essay by Michael O’Donnell in the British Medical Journal, might inspire you delve further into Shaw’s play and its Preface. O’Donnell recently adapted the play “as if for radio” and had performers read their parts, on the 100th anniversary of The Doctor’s Dilemma. O’Donnell’s essay concluded with a barb directed toward the banal teaching of “communication skills” rather than venturing into the “richer territory explored by dramatists”:

“If doctors are to treat illness as successfully as they treat disease they have to enhance their medical experience with some understanding of the world in which they and their patients struggle to survive. Their need, I suggest, is not ‘communication’ but the empathy and understanding that, thanks to Shaw, we and our audience shared on that memorable evening. And we never knowingly deployed a key communication skill.” [BMJ. 333:1338-1340.]

The years immediately following Galens origin and Shaw’s heyday severely tested Ann Arbor and the world beyond. The First World War, a catastrophe for millions, rearranged global geopolitics. The influenza epidemic, known as the Spanish Flu, infected one third of the world population with one in ten (50 million) dying from it. Spain can’t be blamed, for the disease didn’t originate there. As a neutral party in WWI Spain freely reported news of flu activity while other nations restricted information to maintain public morale and to mask information about troop illness. The War spread the flu through close quarters, troop movement, and hygiene disruption. The first U.S. flu wave commenced in the spring of 1918 in military camps and cities. A second wave emerged that September at U.S. Army Training Camp Devens outside Boston. A third and final wave in 1919 ran through the spring. When President Wilson collapsed at the Peace Talks in Versailles, Paris was still in the throes of the flu, and it has been speculated that Wilson was suffering from it. The flu was gone by summer, but H1N1 virus persists.

 

Five.

December 7, 1941, jolted Ann Arbor, like the rest of the country, with the Pearl Harbor attack. Wayne Dertien of Hudsonville shows the December 8, 1941 edition of the Grand Rapids Press, the day after Pearl Harbor (above). This picture (online from 12 June 2013 MLive.com) demonstrates how people saved newspapers or magazines to memorialize a milestone event and, presumably, return to it from time to time. How this will happen now that Gutenberg has gone digital is anyone’s guess, although it should be noted that the convenience of the internet brought me to Mr. Dertien’s picture. We located Wayne and spoke to him recently to get permission to repeat his picture and story, and he commented on how he found the article in a basket his late mother had kept with other articles and magazines that she valued, including an article on the Kennedy assassination.

For urological reasons, 1941 was also noteworthy: a paper that year by Charles Huggins, one of Michigan’s first two urology trainees, led to his Nobel Prize in Medicine in 1966. The other original trainee, Reed Nesbit the first titular head of urology at Michigan, was extraordinary in his own right, as a formative figure in urology practice, education, and research.

In 1941 Nesbit brought two young men to Ann Arbor for residency in his 13th class of residents: Dolphus Compere and Robert Plumb. (Nesbit would eventually have 36 “classes” of trainees.) I got to know Dolph through the tireless work of Maureen Perdomo, one of our development officers in the earlier years of my term as chair. Maureen was totally devoted to our urology alumni and had tracked down Dolph to a retirement home in Fort Worth. Dolph Compere (1916 – 2012) was raised by his mother in Texas after his father, a physician, died of injuries suffered in WWI. Dolph graduated from the University of Texas in 1937 and got an MD from Baylor in 1941. He came to Reed Nesbit and UM for residency in the summer of 1941 and returned to Texas to get married during his December vacation. WWII had broken out just days before the wedding. Returning to Ann Arbor Dolph asked Nesbit for permission to enlist, but Nesbit said he “wasn’t ready.” In 1943 Nesbit released him for duty. We have Dolph’s story of his time in the Pacific Theater and will include it in the Michigan Urology story. Dolph’s co-resident, Bob Plumb, is another story we are pursuing. [Below: Dolph Compere welcoming me and David Miller to Dallas in 2010.]

 

Six.

Events that conspired to cause the two world wars of the past century centered around national misunderstandings among governments that had been high-jacked by extreme points of view. Great efforts were made after WWI to minimize the chance of another great war by promoting international cooperation. Going through papers of University of Michigan president Hutchins at the Bentley Library, I found documents asking him to support a League of Nations, that was established January 10, 1920, and resulted in a Nobel Prize for Woodrow Wilson. The United States never joined and, whether related to that fact or not, a second World War broke out twenty years after ‘the war to end all wars” had ended and the League was dissolved in 1946. With these thoughts in mind, it should give us pause that international cooperation has given way to the deal of the moment. This may reflect a post-truth attitude in human society where are facts are relative or utilitarian, without shared belief in objective truths that transcend nations and disciplines. We see this in politics, in the news industry, and in entertainment. This attitude is infecting journalism, academia, science, and medicine.

Urology makes the world small because of collegial friendships, belief in inquiry, and collaborations connecting us around the world in spite of oceans, borders, walls, or professional turfs. I took this picture a year ago on the Great Wall (above), after a meeting at the home base of one of the most innovative pediatric surgeons and urologists of our time, C.K. Yeung (below).

Whatever the Great Wall divided or protected is long gone. Our guide said it may be the largest cemetery of our species, as fallen workers were buried in or alongside it as they died.

Intellectual walls are equally puzzling. One example is the deep resistance to Lister’s solid evidence for the effectiveness of antisepsis, presented so clearly in The Lancet in 1867. Resistance to that compelling evidence was plainly obtuse. Many iconic leaders of the time were defiant, notably Samuel David Gross, claimed by many at the time to be “The Father of American Surgery,” and immortalized by Eakins with a bloody bare hand during surgery in The Gross Clinic (1875). The year following the painting Gross wrote: “Little if any faith is placed by an enlightened or experienced surgeon on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister.”

An educated mind is literate in science as well as the humanistic thought of past millennia. You can’t have one form of literacy without the other to develop the critical thought necessary to understand the important issues of our time. Many are existential concerns, if not for us, then for those who follow us. [Below: paradigm shifts, Hong Kong Harbor, December, 2017.]

When paradigms shift, as they always and inevitably do, walls don’t serve us well.

 

Seven.

Charles Dickens dealt with many existential concerns of his time, poverty, environmental deterioration, ignorance, crime, violence, malnutrition, and health disparities. These continue today. Born February 7, 1812 in Portsmouth, England, Dickens lived only 58 years, dying after a stroke in 1870. Most notably for my profession, pediatric urology, he was a supporter and philanthropic fundraiser for the fledgling hospital, Great Ormond Street (GOS), where modern pediatric urology began a century later with the work of Sir David Innes Williams (below, flyer for Dickens reading to benefit GOS). Imaginative literature produces colorful language for the medical profession.

Writing under the pseudonym Boz, in 1836, Dickens contributed to a publication called The Posthumous Papers of the Pickwick Club, eventually taking over the monthly periodical. The serialized story became Dickens’s first novel, The Pickwick Papers, and centered on the fictional Samuel Pickwick, Esquire, founder and perpetual president of the club. Kind, wealthy, and rotund, Samuel Pickwick’s phenotype informed a medical condition that came to light more than a century later, in the 1950s. Other figures in the Pickwick Papers included Nathaniel Winkle, Augustus Snodgrass, Sam Weller, and Alfred Jingle. Coincidentally two friends of mine in urology share surnames of those club members.

[The Pickwick Club. Charles Dickens 1838. NYPL Berg Collection.]

Pickwickian syndrome is the obesity hypoventilation condition in which some people, severely overweight, fail to breathe enough to maintain sufficient oxygen levels or low enough CO2 levels, causing sleep apnea. A BMI over 30 kg/m2, hypoxemia, and hypercapnia define the condition. [Kryger M. J. Clin Sleep Med. 8:333-338, 2012.] Other Dickensian conditions include Tiny Tim’s ailment requiring a crutch, perhaps due to Pott’s disease or renal tubular acidosis, and Major Bagstock who exemplified bronchoconstriction & cyanosis. Our own faculty colleague, Howard Markel, did a nice piece on the Public Broadcasting System (PBS, Feb 6, 2016) entitled Was Dickens the first celebrity medical spokesman?

 

Eight.

An essential, existential, meme. The philanthropic idea of Adam Smith was his first big idea. Philanthropy, a generalized warmth toward fellow creatures, extends beyond kith and kin. It is literally “a love of mankind.” This is the foundational condition behind education, health care, and the government of liberal democracy. Freedoms including journalism (“the press”), speech, religion, assembly, lobby, and personal enterprise within the constraints of law, derive from this intrinsic human characteristic of philanthropy.

At the end of a good run, I don’t want to hyperpersonalize my term as our department’s second chair and 9th urology chief, from Cabot to Montie, I was only as effective as the people around me: our staff, faculty, nurses, PAs, and residents are wonderful. I heard a recent interview on NPR that included an alleged quote from the film director Orson Wells, who said something to the effect that the role of a director was “to preside over accidents.” Whether I can trace this quote back to its origin and find it to be a true fact or not, is less important than the thought itself that any director, chair, administrator, or team leader is at the mercy of the randomness of the actions, performances, beliefs, or events that surround the stakeholders and bystanders of the enterprise.

Stochastic events are central to all parts of biology, whether genomic function, epigenetic determination, molecular assembly, behavior of any self, or teams. Life is attended by stochastic randomness, events and processes that may be explained by probability distribution, but are not precisely predictable. In this sense they are, perhaps, accidental or random. These events and processes may be mathematical, chemical, epigenetic, or social like an Orson Wells play or the management of an academic urology department. Ideas and memes, possibly the most complex biologic products, are also stochastic, as they arise. They may be good or bad, useful or destructive, true or false. We may think our dreams and ideas are accidental, stochastic as they seem to appear randomly, although they are not quite random – they have sources, coming from some conditions, memories, anxieties, wishes, or other places in the mind.

The idea of stoichiometry, so close in sound, is something quite different, intending a precision based on the chemical idea of conservation of mass. A film director or a leader of an academic clinical department needs people, props, and data. For the director, a film has a budget, it needs equipment, sites, actors, support teams (including those “best boys”), props, food, payroll systems, and a distribution plan. These are the necessary components of motion pictures. The many performances that comprise the final product, however, cannot be determined by numbers, data, or stoichiometry. Although performances may be studied, rehearsed, and coached, they are ultimately accidental. A director must provide milieu, and perhaps inspiration, but if good actors are on the scene, a good director might be most effective by getting out of the way of the characters and their art. A producer may go to an accountant to help manage the accounts, but not to direct a film. Academic units are not greatly different.

 

Nine.

Philanthropy is fundamental to humanity at the level of family and tribe, it is built into our DNA as it is in other primates and many other mammals. The love and philanthropy that we give to family and neighbors preserves and grows society, in that it is a specific and necessary component of the human condition. It is part of the stoichiometry of our species, it is a proportionate part of the mix, albeit expressed variably from person to person. It is at the heart of the early religions and cultures that defined humanity and in many cases tried to extend the idea beyond any specific family, culture, nation, or religion. Philanthropy is stoichiometric in that it is a specific and essential part of the mix of our species, but it is also stochastic or random, in the binary sense that it can happen or not happen.

Philanthropy in this sense, as a meme, had its most insightful articulation by Adam Smith, in the first sentence of his first book, The Theory of Moral Sentiments, when he wrote in 1759:

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

As a meme, this particular thought of Smith’s was not totally random in that it was shaped by millennia of human thought, his personal upbringing and education, and the society surrounding him (the astonishing Scottish Enlightenment). But as a thought that inspired his book, it popped up in his brain and was shaped into a very compelling and durable meme – the generalization of philanthropy to all of humanity. While this aspiration had been set out in the great human religions long before Smith, his meme was not compelled by a deity or demanded by a social code.

Smith recognized that each person has some nugget of generalized philanthropy within. In this complex world of 7 billion people, interwoven with perhaps only a few “degrees of separation” from each other, the meme of Adam Smith, generalized philanthropy and its first cousin, global human cooperation, is more than just a meme, it is now an existential necessity. Our genes compelled familial and tribal philanthropy that have carried us this far to human domination of the planet through the powerful tools of education, science, and technology. However, we can’t go much further without full deployment of the memes of philanthropy and global human cooperation.

 

Ten.

Leadership change is around the corner for our department and it comes at a fortuitous time with the Michigan Urology Centennial about to start later next year. This will signal a change in the weekly What’s New email communication of the Department of Urology, as that communication format and paradigm should be a choice of the next administration. On the other hand, the web-based monthly version, Matula Thoughts, will continue as best it can by this writer at the web site matulathoughts.org. The quirky title derives from the uroscopy flask that identified the entire medical profession for many centuries. Laennec’s invention of the stethoscope in 1816, supplanted the matula and is a far better symbol for the medical profession, epitomizing the idea of listening. Furthermore, the stethoscope is far more portable and durable than glass flasks, and contains little in the way of biohazard, except for an occasional bit of wax.

 

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

Birthdays, graduations, and centennials

July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.


In July we welcome new residents and fellows to our urology program (more about them in the next few months) and it’s a nice time for them to be in Michigan. Si quaeris peninsulam, that is if you seek a pleasant peninsula (as the state motto goes), this is the time of year to explore this double peninsula with its 65,000 inland lakes and bordering four great lakes. Michigan is an appropriate name, coming from Ojibwe, meaning “large water.” Indigenous people inhabited this area for millennia, until 17th century Europeans moved in and called it home. [Below: Wikipedia.]

We celebrated America’s birthday on July 4 (fireworks above), but Michigan’s birthday is open to debate. Michigan Territory dates back to June 30, 1805 and statehood declaration was January 26, 1837, but an actual “birthday” doesn’t seem particularly important, federalism trumping state particularism. Michigan gained its upper peninsula in 1836 after the Toledo War. Like the ridiculous and bloodless Pig War, described on these pages last month, the Toledo Dispute grew out of conflicting geographic identities that quickly escalated, although some blood was spilled in Toledo when a young Ohio man with a penknife stabbed a deputy sheriff from Monroe, Michigan during a scuffle. Resolution of the dispute by the US Congress, during the presidency of Andrew Jackson, awarded Ohio the Toledo Strip while Michigan gained its Upper Peninsula. Annual Buckeye vs. Wolverine or Spartan contests ritualize the Toledo dispute although, for all the existential threats facing our species today, it is ridiculous that a Michigander might hate an Ohioan or a Buckeye despise a Wolverine.

Like most biologic lifeforms, we are engaged in life-long tests for survival and relevance, the relevance reflecting the necessity of belonging to some thing. Hard-wired into our genes, honed by millennia of trial and error, is the need to belong to a pack, a clan, a team, a family, a school, a community, a nation, or some belief system. Kurt Vonnegut satirized that notion of identifying with an organization or a particular geography in his book Cat’s Cradle (1969), where pride of membership in the General Electric Company, for example, or being a Hoosier seemed ludicrous. While Vonnegut challenged the meaning of such belonging, our genes compel us to those memes of identity and our national, sectarian, and religious identities are the most compelling. Identity as “an American” certainly supersedes identity as a Michigander, but endurance as a species may require a much stronger identity meme, namely that of being a global member of Homo sapiens. How we get there is anyone’s guess.

 

Two.

Beginnings. The Fourth of July was an arbitrary choice. The Resolution of Independence, legally separating 13 colonies from Great Britain, was signed by the Second Continental Congress on July 2, 1776. Congress then attempted to agree upon a document to explain the separation. The drafting of The Declaration of Independence had begun on June 11 by a Committee of Five led by Thomas Jefferson. Congress saw an early draft on June 28, but controversy over wording continued to July 2 and spilled over until agreement was reached on July 4. Signatures by state delegates didn’t begin until August and were not completed for several months [Danielle Allen, Our Declaration. 2014.].

This ambiguity gives us some license to pick a starting year for Urology at the University of Michigan. Genitourinary surgery was most certainly practiced from the earliest days of surgery in Ann Arbor but modern urology, with its educational and investigational components, is something substantially more. The actual term, urology, was invented by Ramon Guiteras, a genitourinary surgeon in New York City who founded the AUA in 1902. His book, Urology, in 1912 was one of the first 20th century texts to define the field, followed in 1916 by that of Hugh Cabot (below) an internationally famed Boston surgeon, with Modern Urology.

Disillusioned by the mercenary nature of his practice environment, Cabot accepted a “fulltime salaried” position at the University of Michigan as Chair of the Surgery Department in 1920. He brought modern urology to Ann Arbor, became the Dean of the Medical School, built a great multispecialty group practice, and presided over construction of a 1000 bed hospital that opened in 1926. His first urology trainees, Charles Huggins from Boston and Reed Nesbit from California, did well in their careers, influencing urology, worldwide medicine, and international events. Considering the various options, it seems reasonable and convenient to declare 1920, the year Cabot came to Ann Arbor, as the starting point for the Centenary of Urology at the University of Michigan.

 

Three.

Public universities. When Cabot arrived in Ann Arbor, the University of Michigan was already more than 100 years old and differed from any other institution the Bostonian had experienced. Medical education in Boston had been based on medical school relationships with separate private and public hospitals. When the University of Michigan established its own teaching hospital in 1869, however, it invented a new and different model of medical education. This has become a wholly owned and operated integrated health system containing a full range of medical practice and a research enterprise that comprises a rich milieu for professional health care education. The University of Michigan is further unusual in that it is a public university (birthdate in 1817) that pre-existed its own state (birthdate 1837).

The facet of American Exceptionalism that may matter most in the long run will likely be the magnificent patchwork of higher education consisting of public universities, private universities, liberal arts colleges, technical schools, research universities, professional schools, community colleges, and faith-based colleges functioning independently to build tomorrow’s citizenry. This patchwork is quite different from a single higher education system managed by a central state.

Public and not-for-profit colleges and universities in this country are shaped not only by their particular institutional legacies, but also by their public responsibilities. Because we are a free country, an entrepreneurial and commercial side of higher education also exists, with ultimate responsibility to owners, corporate officers, and shareholders. This sector is not the strongest point of the American patchwork.

The public status of a university and health system brings particular constraints and responsibilities. Constraint starts at the top for Michigan with ultimate authority at the board of 8 publically-elected regents, responsible to the people of the State of Michigan. Each regent also brings an individual sense of the missions of the university and its health system, aligned to the interests of their political party. Public responsibilities of public universities reflect public needs and aspirations in a larger sense, and convey to their learners, employees, and patients.

Private universities and health systems have their own boards and ultimate responsible parties, with values, needs, and aspirations are not necessarily the same as those of public institutions and therefore may align differently with learners, faculty, and employees. Even so, their not-for-profit status gives them public responsibilities.

A few months ago, these pages quoted a short campaign speech of presidential candidate John Fitzgerald Kennedy on the steps of the Michigan Union at 2 AM October 14, 1960, laying the seeds for the Peace Corps. While, JFK didn’t seem to quite understand how public universities were “maintained,” his point that they had a higher purpose was well taken: ” Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it.”  [Full speech below.]

 

Four.

Centennial. It is fitting that new leadership of this department of urology will be in place as we celebrate the Michigan Urology Centennial. Ceremonial interludes of this sort allow reflection, alignment, and revitalization before stepping into a new period. For purposes of planning we can start our Urology Centennial at the Nesbit Reunion in the autumn of 2019 and close it at the Nesbit Meeting in the autumn of 2020, roughly corresponding to a year in the academic calendar, but giving Nesbit alumni and friends two chances to get back to Ann Arbor for scientific and social events. A committee is already at work on this, under the leadership of Dr. Meidee Goh.

Before entering our second century, I’d like to clear up a nagging misconception. State support of public universities is dwindling nationally and this is particularly true in Michigan. Furthermore, virtually no state appropriations come to the UM health system or its medical school, aside for payment of services. It is true that other public medical schools have state-funded salary lines for faculty, but this is not so at UM. Nonetheless, many well-meaning Michiganders think their tax dollars support Michigan Medicine and that misbelief has led to hard-feelings in the competitive world of health care. One excellent referring physician from mid-state sent a rough email message to one of our faculty after hearing the UM “would not accept” his patient. In this case it wasn’t that Michigan Medicine would not accept the patient, but rather the “narrow network” of a stingy private insurer would not include Michigan Medicine in its network because Michigan’s costs have indeed been higher than average. It didn’t matter that this patient needed a complex surgical operation that is not done in most hospitals. Kudos to the referring physician for getting angry on behalf of his patient, but the anger was misdirected and to add a bit of insult to injury, the physician believed his taxes supported Michigan Medicine (wrong) noting that we would have cared for the patient under Medicaid or without any insurance (correct).

 

Five.

 

Visiting another peninsula. I was guest at another great public medical school and urology department that recently celebrated its first centennial, the University of California San Francisco. Our two institutions share many features and a number of Michigan medical students, trainees, and former faculty populate UCSF Urology. Unlike Michigan Medicine, UCSF is physically separate from its parent campus, across the Bay at Berkeley. The UCSF teaching hospital was founded in 1907, the year after the San Francisco Earthquake, and was the first university hospital in the University of California System. Schools of Medicine, Nursing, and Pharmacy co-located with the medical school on Mount Sutro along Parnassus Avenue and, like Michigan, the Parnassus Campus outgrew its geographic limits. While we at Michigan expanded to North Campus, East Ann Arbor Medical Campus, and other sites, USCF is also expanding widely, most notably to its grand new Mission Bay Campus. [Above: UCSF teaching conference with residents and an attentive canine named Peanut. Below: UCSF Assistant Professor Lindsay Hampson, UMMS 2009, next to Professor Kirsten Greene.]

[Below: top, Anne Suskind, Nesbit 2014 UCSF Assistant Professor and faculty David Tzou; bottom, Thai cooking class lunch with residents Heiko Yang UMMS 2016, Chef Sunshine, Adam Gadzinski UMMS 2013.]

Similar to Michigan, UCSF Urology celebrates graduation of its chief residents and fellows with dinner for families, faculty, and the entire resident cohort. Junior residents gently “roast” selected chiefs, just as we do in Ann Arbor. David Bayne, one of the graduating chiefs, was quoted by roaster Ian Metzler (whom I had met a few years back on the interview trail) as having once said: “Academic medicine is like a pie-eating contest, where the prize is more pie.” [Below: David & Shani Bayne.]

[Above: Peter and Laura Carroll at the St. Francis Yacht Club.]

 

Six.

Michigan’s chief dinner took place at our Art Museum the following week in June. Our graduating chief residents and fellows join a fine tradition of urology education in Ann Arbor going back to 1926, after UM opened its University Hospital (the fourth since 1869) and Hugh Cabot brought the first two urology trainees to Michigan. Since then at least 329 urology residents and fellows have come from this program. The exact number remains elusive as we don’t have a full accounting of all the fellows or the residents trained at the historic Wayne County General Hospital branch. Khaled Hafez and Gary Faerber had superb runs as program director over the past decade and the reins now pass to Kate Kraft. Our new PGY1’s were on hand for the evening.

[Above: Kate Kraft introducing new PGY1’s Kyle Johnson, Katie Marchetti, Roberto Navarrete, & Javier Santiago. Below: Amy Luckenbaugh and parents.]

Graduating chief residents are transitioning to fellowships: Amy to Vanderbilt Uro-oncology, Amir Lebastchi to the NIH Uro-oncology, James Tracey to Guys’ Hospital Andrology & Reconstruction, and Yooni Yi to UT Southwestern Dallas Reconstructive Urology. [Below: top, Amir with family and friends; middle, James and family, bottom, Yooni and parents.]

Fellows: Duncan Morhardt to Boston Children’s Pediatric Urology, Elizabeth Dray Columbia SC practice, Tudor Borza to University of Wisconsin faculty, and Courtney Streur joins our pediatric urology faculty. [Below: Duncan and wife Tina; Elizabeth with father Greg and husband David; Courtney between Professors John Park and Daniela Wittmann; Tudor between Ted Skolarus and Jeff Montgomery.]

 

Seven.

Memes. A few months back we raised the idea of the meme in relation to the blind eye metaphor. A meme is a parcel of self-replicating information that, like the biological gene, is capable not only of replicating into perpetuity, but also can modify itself through time and cultures such that the fittest versions survive. Richard Dawkins invented the neologism in his book, The Selfish Gene in 1976, noting that the concept pre-existed his description. He postulated that if one fundamental principle existed for all life it would be “that all life evolves by the differential survival of replicating entities.”

“I think that a new kind of replicator has recently emerged on this very planet. It is staring us right in the face. It is still in its infancy, still drifting clumsily about in its primeval soup, but already it is achieving evolutionary change at a rate that leaves the old gene panting far behind. … The new soup is the soup of human culture. We need a name for the new replicator, a noun that conveys the idea of a unit of cultural transmission, or a unit of imitation. ‘Mimeme’ comes from a suitable Greek root, but I want a monosyllable that sounds a bit like ‘gene.’ I hope my classicist friends will forgive me if I abbreviate mimeme to meme. If it is any consolation, it could be thought of as related to ‘memory’ or to the French word même. It should be pronounced to rhyme with ‘cream’.” [Dawkins. P. 248-249. The Selfish Gene. 40th Anniversary Edition.]

That idea of the soup of human culture corresponds to the concept of superorganisms created by eusocial species, as E.O. Wilson has elegantly described in his work. Just as the gene is the building block of information that constitutes each individual, language and memes comprise the information that constitute the superorganism. Germ theory, shoe lace tying, tweetstorms, and the meme itself, are successful memes.

 

Eight.
The soup of human culture meme recalls a sensational episode of plagiarism involving Maurice Maeterlinck (1862-1949), Belgian author and Nobel Laureate (Literature, 1911). Well-known in his time, he had a stint in the United States produce film scenarios for Samuel Goldwyn in 1919, although none became a movie. One scenario was The Life of the Bee, although Goldwyn heartily rejected the idea of a movie about a bug. Back home in 1926, Maeterlinck published a book called La Vie des Termites (The Life of White Ants), although reportedly admitted he never actually seen a living termite. His source, boldly copied, was obscure work published in 1923 in Afrikaans by Eugene Marais, called The Soul of the (White) Ant. [Wikipedia.]

Extensive field work observing termites “on the veld,” led Marais to the idea of “the organic unity of the termitary” analogous to the organ-based composite human body. Maeterlinck appropriated the Marais theory 3 years later, boldly plagiarizing the text. Marais threatened a lawsuit although didn’t pursue it due to financial barriers. A subsequent English edition of Marais’s original book contains an introduction by its translator, Winifred de Kok assigned priority and credit to Marais, while pointing out the plagiarism. [Eugene N. Marais. The Soul of the White Ant. Methuen & Co. London. 1939.]

Tracking down the meme story, I found the Dawkins neologism and then noted the Maeterlinck transgression in Wikipedia, where University of London professor of biology David Bignell described the episode “a classic example of academic plagiarism.” Not wanting to fall into the realm of plagiarism myself, I tried to track down the evidence for this claim (after all, Maeterlinck was a Nobelist!) and went to the reference cited in Wikipedia but couldn’t find the actual claim. I did find an email address for Professor Bignell, composed my question, and pressed “send.” A reply from the next morning was a wonderful surprise. Professor Bignell wrote:

“Thank you for your message. This has rather made my day. I am long since retired, but it’s always stimulating to be dragged out of retirement with a question about termites, however obtuse. … The only public reference I have ever made to the Marais/Maeterlinck issue was in my Inaugural Lecture in October 2003. In the UK, newly promoted Full Professors are obligated to give a public lecture (widely advertised and open to anyone to attend), and I might add a terrifying experience as it’s your one opportunity to make a complete fool of yourself without any subsequent means of redress. I stuck to my subject (termites) but included a reference to the plagiarism, as it had become celebrated in the world of science, and bizarrely was one of the reasons why termites sometimes command public attention.”

 

Nine.

Mimes & plagiarists. Mimicry is the biological phenomenon in which one organism evolves characteristics that resemble those of another group. This is akin to a theatrical phenomenon, the performance art of acting out a story or a persona, the term coming from the masked dancer in ancient Greek comedy called Pantomimus. Marcel Marceau, French actor and survivor of the French Resistance in WWII, became the most famous meme of modern times and brought silent mimed exercises to a high art, inspiring Michael Jackson among others.

[Publicity photo of Marcel Marceau for appearance in Seattle, Washington, 1974. Wikipedia.]

[Mime artists Jean & Brigitte Soubeyran in the play “In the Circus” 1950. Wikipedia.]

As a young surgeon I tried to mimic attributes of my key role models. At UCLA they were William Longmire, Rick Fonkalsrud, Don Skinner, Rick Ehrlich, RB Smith, and Jean deKernion. In London it was David Innes Williams and in Boston, Judah Folkman and W. Hardy Hendren. Each set high bars for thinking, clinical acumen, surgical skill, patient rapport, teaching, and wisdom. Role modeling is essential to professional education, where the so-called hidden curriculum of behaviors is as important as the conceptual knowledge and skills that are imparted.

The truism that imitation is a high form of flattery, however, stops short of plagiarism. Plagiarism is theft of an original idea or work and representation of it as one’s own. Most work of civilization is collaborative with some decree of mimicry, but deliberate plagiarism betrays civilized behavior and represents fraud, theft, and deceit. Erosion of trust in science and medicine is particularly dangerous. Even though plagiarism seems to be a rare event in academic circles of urology, it happens. Most people can easily distinguish the difference between passing along memes and outright plagiarism. Science, literature, and the other arts build upon the imagination of our predecessors, and the memes they created or passed along replicate only through re-use, evolving in that reuse through the trial and error of application (or errors in transcription). The fairness of civilization demands that credit be given when credit is due, recognized through patents, copyrights, and academic integrity.

Plagiarism happens in a number of ways. Some people, unfamiliar with traditions of intellectual honesty and personal integrity, may resort to lazy plagiarism of an idea, paragraph, illustration, or even more. Other plagiarists rationalize that their “scholarly methods” allow cutting and pasting without attribution as “honest mistakes.” I’ve heard a number of these excuses even from a few otherwise respected colleagues when caught in the peer review process. On the other hand, when journalist James Stewart wrote his factual account, Blind Eye, he used a very widespread metaphor (a meme) for the dark and true story of educational supervisors who turned a blind eye to terrible misdeeds of an aberrant human being. [Blind Eye. 1999. Simon & Shuster.] Stewart, however, didn’t need to acknowledge Admiral Nelson for the meme, we would call that fair use, and such acknowledgement would border on pedantic explanation, when no explanation is necessary. Blind eye is now part of our language.

We all replicate memes, but gross plagiarism discovered occasionally during journal review makes me angry. It wastes the time of the reviewer and discredits our “brand” as scholars in the eyes of the public. We expect our resident graduates to mimic the best of what they observe and then to build on that to become their own originals in thought and action. Furthermore, we hope they will never turn a blind eye to plagiarism or other breaches of civility.

 

Ten.

Graduating urology trainees carry with them rich identification with their training programs and join unique cadres of fellow alumni that may reach back more than a century, as for Johns Hopkins, the first formal urology program. Most physicians identify reverently with their residency training sites. Human complexity allows us to find relevance in numerous contexts and, to that end, medicine as a generality for health care, is a greater belief system than mere occupation or specialty. More than most professions, medicine is central and essential to life and its fulfillment. We each begin life as patients, are among the rare species that routinely need assistance for childbirth, and we are the only species capable of complex therapies based on shared, verifiable, and accruing knowledge and technology. Medical practice is, above all, a performance art.

The art of medicine exists in the choices of excellence, kindness, attentiveness, education, innovation, skills, investigation, and fiduciary duty brought to the daily work of clinical care, and updated in daily practice through immersion in the soup of human culture. We extend that immersion through other forms of art, as the title of a book by Robert Adams provocatively claims. [Art Can Help. Yale University Press, 2017.] Visual, musical, and other performance arts inspire thought, admiration, criticism, inquiry, and further creativity. The arts help us answer our continuous tests for relevance as trainees, new graduates, and old hands in urology.

Thanks for reading Matula Thoughts this July, 2018.

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

 

Kennedy’s speech. When you listen to a recording it differs somewhat from this official printed version.

“I want to express my thanks to you, as a graduate of the Michigan of the East, Harvard University.
I come here tonight delighted to have the opportunity to say one or two words about this campaign that is coming into the last three weeks.
I think in many ways it is the most important campaign since 1933, mostly because of the problems which press upon the United States, and the opportunities which will be presented to us in the 1960s. The opportunity must be seized, through the judgment of the President, and the vigor of the executive, and the cooperation of the Congress. Through these I think we can make the greatest possible difference.
How many of you who are going to be doctors, are willing to spend your days in Ghana? Technicians or engineers, how many of you are willing to work in the Foreign Service and spend your lives traveling around the world? On your willingness to do that, not merely to serve one year or two years in the service, but on your willingness to contribute part of your life to this country, I think will depend the answer whether a free society can compete. I think it can! And I think Americans are willing to contribute. But the effort must be far greater than we have ever made in the past.
Therefore, I am delighted to come to Michigan, to this university, because unless we have those resources in this school, unless you comprehend the nature of what is being asked of you, this country can’t possibly move through the next 10 years in a period of relative strength.
So I come here tonight to go to bed! But I also come here tonight to ask you to join in the effort…
This university…this is the longest short speech I’ve ever made…therefore, I’ll finish it! Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign. I come here tonight asking your support for this country over the next decade.
Thank you.”
Senator John F. Kennedy
October 14, 1960

Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

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

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

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

 

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

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

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

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

 

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

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

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

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

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

 

Four.

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

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

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

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

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

 

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

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

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

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

 

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

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

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

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

[Below: Jean and Mary DeKernion.]

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

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

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

 

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

[Above: Grady Festschrift group photograph.]

 

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

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

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

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

 

Eight.

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

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

 

Nine.

 

 

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

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

 

 

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

[Above: The Rock.]

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

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

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

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

 

Thanks for reading Matula Thoughts.

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

Matula Thoughts July 7, 2017

DAB What’s New July 7, 2017

 

The Fourth, stories, & art

3789 words

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

Flag

One.              

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

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

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

Fireworks2

[Fireworks, Barton Hills 2017]

 

Two.

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

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

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

 

Three.

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

Ian & Ted

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

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

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

 

Four. 

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

Point counterpoint

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

 

Five.

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

Fire_ants_01

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

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

 

Six.

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

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

400px-RoswellDailyRecordJuly8,1947

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

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

 

Seven.          

Lapides copy 3

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

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

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

 

Eight.

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

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

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

Bronze star

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

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

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

 

Nine.

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

 

Ten.

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

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

Gibbes

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

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

AAAF 2016

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

 

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

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

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

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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

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


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


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

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