Transitions.

DAB What’s New Dec 1, 2017

3818 words

 

One.

The Michigan Theater, seen above on a crisp autumn evening, is one of Ann Arbor’s many delights, making it easy to “sell” our town to medical students who interview for urology residency. Reflecting the halcyon days of motion picture palaces, the theater opened January 5, 1928 with grand lobbies, 1700 seats, a Barton theater organ, and an orchestra pit. Now, after ninety years of capital campaigns and restorations, the building has three auditoriums and is the center of the Michigan Theater Foundation, a world-class non-profit center for fine film and other cultural events. Its State Theatre, across the street, reopens this month after a well-earned renovation. Michigan Theater hosts the Ann Arbor Symphony Orchestra, Cinetopia International Film Festival (in partnership with the Detroit Institute of Arts), organ concerts, and other live-stage events. When days in the next few months get gray, slushy, and cold, the Michigan Theater is a wonderful refuge and it’s equally delightful the rest of the year.

“I’ve seen this movie before” is a phrase in vogue for recurrent phenomena and so it seems with the autumn ritual of residency applications. Fourth-year medical students travel around the country as “sub-interns” to audition at training programs in hopes of securing 5 to 6-year residency slots. Yet, every annual cycle presents a unique array of new faces, talents, experiences, and energies of candidates visiting our Ann Arbor program. This recruiting season has been particularly good, marked by nearly 70 astonishing medical students who interviewed for four residency positions to start here on July 1, 2018, as the class of 2023.

Just as we rank the students, they rank us among the other programs they like and a computer makes the binding national match. Most applicants we see will become successful urologists and most programs they rank will train them excellently, evidence that our medical schools and professional organizations have created high standards, with narrow Gaussian distributions of quality. This is to say, the very best programs and candidates falling on the right side of the curve are not grossly dissimilar by most measures from the programs and candidates on the other side. A theoretical program variability curve (blue) and wider student applicant curve (red) illustrate my belief that some applicants are potentially “better” than any of our programs. That should be no great surprise, as it indicates Darwinian principles at work: some of our successors should, by all rights and intents, surpass those of us who teach them.

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Two.
What does it take to go from applicant to successful resident? Most people we interview will become excellent residents and urologists who will impact their communities and practices significantly, and some will advance the field of urology in major ways. Before students create their preference lists, they need to get in the door for rotations and interviews. This requires good Step One board scores and excellent medical school performance data. Since most schools are “pass-fail,” applicants must demonstrate noteworthy performance in their clinical clerkships, such as “honors” in their deans’ summaries and strong letters of endorsement. When recommendations come from colleagues we know, with good track records of producing students who become excellent residents, we pay attention. Honorary society membership, selection to AOA for academic work or the Gold Humanitarianism Society, helps demarcate successful applicants. Exemplary social behavior is an important feature and successful performance on teams, such as college sports and humanitarian efforts, is also typical of our applicants.

Test metrics, honors, and accolades are surrogates for the attributes we seek in our residents and future colleagues. We want individuals with intellect, empathy, ingenuity, resilience, and good humor. Good residents and good colleagues tolerate personal inconvenience to help their patients and teams. Particular metaphors illustrate our affinities. The people we seek have the “fire in the belly” to do the daily work and to solve meaningful problems. They “go the extra mile,” or add-on the “extra case” at the end of the day when the going gets tough. We need people who work well in teams, yet are effective leaders when the opportunity or need arises. Candidates similarly seek attributes of training programs. Surveys and “field notes” over the years identify important factors in play for applicant preferences such as program depth, established mentorships, institutional culture, geography, global opportunities, and climate.

Two new features of our program will come on line. Steve and Faith Brown of California created a scholarship for a medical student, preferably from UM, entering our urology residency each year. The Brown scholarship will help residents with research projects or unique educational experiences. An intermittent 5th residency/research position, intended for a physician-scientist and established with the NIH and AUA, will start in 2019 and last seven years.

 

Three.
The Gaussian distribution of residency programs, narrow and steep, reflects the fact that nearly all are fully capable of preparing trainees for excellent urologic careers. The wider applicant curve reflects my belief that many of our trainees have the capacity to be better than we (the faculty) are now. In fact, this is our goal. We want to train residents who will leverage the best of what they learn and see from faculty today to improve urology practice and research throughout their ultimate careers. In their own time, today’s residents and fellows will discover new knowledge, recognize new paradigms, invent better technologies, create novel operative solutions, and find ways to deliver health care more safely, efficiently, generously, equitably, and with greater kindness. If we do our work properly, our trainees will be more adaptable and creative in the environments of their tomorrows, than we could be if we cloned ourselves.

Johann Carl Friedrich Gauss (1777-1855), the only child of a poor family, was born and raised in the Duchy of Brunswick, now Lower Saxony, Germany. A child prodigy, he attracted the interest of the Duke of Brunswick who supported his education locally and at Göttingen University. Gauss’s doctoral thesis in 1797 offered a proof of the fundamental theorem of algebra, that every polynomial equation with real or complex coefficients has as many solutions as the highest power of its variable. The duke’s philanthropic investment paid off well, as Gauss became known as “the foremost of mathematicians” (Princeps mathematicorum) and the most influential mathematician in the past millennia, impacting numerous areas of mathematics and science in general. Many echoes from Gauss’s brain reverberate today. In addition to Gaussian distribution we have the Gauss unit, Gauss law, Gauss formula, Gauss platform, Gauss elimination, Gauss-Bonnet theorem, and even the Gauss rifle. The web reveals an astonishing array of Gauss’s quotes, revealing a humorous and humanitarian mind. (Below: Daguerreotype of Gauss on his deathbed. Wikipedia.)

 

Four.
Universities are civilization’s best bet for its future, teaching tomorrow’s citizens and builders, and expanding today’s knowledge. Universities explore “the nature of things” and public universities play a particularly important role. A quote by David Damrosch stays with me:

“A report by the Carnegie Council in 1980 began by asking how many Western institutions have shown real staying power across time. Beginning with 1530, the date of the founding of the Lutheran Church, the authors asked how many institutions that existed then can still be found now. The authors identified sixty-six in all: the Catholic Church, the Lutheran Church, the parliaments of Iceland and of the Isle of Man – and sixty-two universities (Three Thousand Futures).” [Damrosch, D. We Scholars. Harvard University Press. 1995, p. 18.]

Purposeful building of successive generations cannot be left to chance or entirely entrusted to government, religious entities, or the private sector. Nor should this be entrusted to any single university system, whether state or private. A diversity of universities, public, private, and ecclesiastical (in collegial or sometimes sharp competition with each other) will be the best way to educate successive generations, innovate technologies, and create and test new ideas for tomorrow. Universities must accommodate the immediate milieu and stakeholders of today, while taking the long view for subsequent generations. Gauss’s university is exemplary.

The University of Göttingen was founded by King George II of England in 1734 (as Elector of Hanover) and quickly became a center for the nationalistic reawakening of the German lyric and national poetry.  Encyclopaedia Britannica credits the university with releasing Germany “from the confines of the rationalism of the Enlightenment and from social convention.” Gauss studied at Göttingen from 1795 – 1798, but around its centennial in 1837 the university took a reputational hit when seven professors were fired for political unrest. Luster was restored before its bicentennial particularly at its Mathematical Institute, that Gauss had once led. Göttingen has produced 40 Nobel prize winners including Max Born, James Franck, Werner Heisenberg, and Max von Laue. The strong mix of humanities and science at the University of Göttingen is noteworthy evidence that these two facets of creativity are inseparable, divided only by parochial and unimaginative perspectives. A century younger than Göttingen, The University of Michigan is no less rich in humanities and science. All universities need to figure out better ways to merge those two fundamental sides of knowledge.

 

Five.

Galens 91st annual Tag Days began yesterday and will run through tomorrow. Medical students and faculty at the University of Michigan created Galens Medical Society in 1914 for student advocacy and as a social bridge between students and teachers. The name choice is both obvious and obscure. Galen was one of the early great names in medical practice and study, but it remains a mystery as to why that particular name was selected for this medical society. Galens Society at Michigan created an honor system, obtained secure student lockers (theft was a problem even in those halcyon days), and established a student lounge. In 1918 Galens members held the first Smoker, a series of skits performed by Galens men. Galens shifted its focus in 1927 to raise money for children with Tag Days, wherein students solicited faculty and community members, a tradition that continues the first weekend of December in the Medical Center and the streets of Ann Arbor. The Silver Shovel Award began in 1937 to honor faculty who have shown extraordinary commitment to teaching medical students.

At some point Galens opened its doors to women medical students, reinvigorating the organization. Galens initiated the Mott 8th floor project in 1964 to house its Workshop for Children that had been ongoing since 1928, but lacked a permanent site. A chapel and student lounge were also created in that space. Galens contributed funds for the Mott Pediatric ICU in 1968 and in the 1980s made a similar contribution to St. Joseph Mercy Hospital for its Pediatric ICU. In 2006 Galens came up with $200,000 for the Child and Family Life Playrooms in the new Mott Hospital. In addition to the Mott Child and Family Life Program, Galens has supported Ozone House, Foundations Preschool, Children’s Literacy Network, The Corner Health Center, and Special Days Camp, among other worthy projects.

Galens today includes about 120 medical students and 13 honorary faculty members. During Tag Days students on street corners sell tags that raise nearly $100,000 for Mott efforts and other children’s programs in Washtenaw County. In addition to The Smoker, Galens supports a Welcome BBQ, a tailgate, and a year-end banquet. A Galens Loan Fund helps medical students for their interviewing costs, that easily can cost students $5,000 – $10,000 as they travel around the country in their fourth-year interviewing for residency. Next year’s Smoker, by the way, will be March 2 and 3 at Lydia Mendelssohn Theatre.

 

Six.
Michigan men.

Francis Collins returned to Ann Arbor last month for the M Cubed Symposium and gave an inspiring talk that he called “NIH: National Institutes of Hope.” As a faculty member here in the Department of Human Genetics, his team figured out the genetic basis of cystic fibrosis. He went on to co-direct the human genome project and is currently NIH Director. Collins spoke about the considerable footprint of UM in medical research and our relatively large portion of the NIH budget.

Dr. Collins offered three reasons for splicing “hope” into the NIH acronym. First is the role of the NIH in uncovering life’s foundations; second is the NIH intent to translate discovery into health; and third is the synergy in the socialization of science, that is the idea that collaborations are the best way for the scientific community to “move forward, together.”

The NIH origin dates back to July 16, 1798 when Congress established the Marine Hospital Service “for the relief of sick and disabled Seamen,” recognizing that their healthcare was a responsibility of the government. The Marine Hospital Service fell under the Treasury Department and a monthly tax of twenty cents was deducted from the pay of merchant seamen, making this America’s first prepaid health care system. Less than a year later, legislation extended the benefits of the Marine Hospital Service to Navy and Marine Corps personnel. In 1875 a new law directed the President to appoint a Surgeon General of the Marine Hospital Service with advice and consent from Senate. Interstate quarantine authority was granted by Congress in 1890. The name of the service was changed in 1902 to the Public Health and Marine Hospital Service, eventually growing into the NIH, now intended to improve knowledge and extend services to improve health. The current budget exceeds $32 billion.

John Park was recognized as Clinician-of-the-Year at the Michigan Medicine Awards Dinner last month. A superb pediatric urologist, quintessential teacher and mentor, and leader as Surgeon-in-Chief at Mott, John is one of the most respected and beloved clinicians of Michigan Medicine. The yearly awards celebration was instituted by former dean Allen Lichter, continued by Jim Woolliscroft, and now is fine-tuned by Marschall Runge, Carol Bradford, Bishr Omary, and David Spahlinger. (Below: Park family)

 

 

Seven.
When calendar years close out, pundits tally major events and accomplishments, as if to predict what future generations might mark as notable for that year. Some events and findings this year, unrecognized by most of us likely will rise to great significance in future times. At this moment, as of December first, some breakthroughs of the year are already acclaimed as important, although much can yet happen for good or for bad this last month of the year.

Science magazine traditionally announces its “breakthrough of the year” with 9 runners-up, as a result of a “people’s choice” poll. Likely contenders for that list will be: observation of gravitational waves by three separate observatories, thereby supporting Einstein’s general relativity theory; CRISPR gene-editing to correct the mutation causing hypertrophic cardiomyopathy in a viable human embryo (similar work was reported in China a few years ago); neutron star collision (kilonova) witnessed at LIGO; and human-pig hybrid creation at Salk.

Editors and writers of Science magazine in 2016 picked the detection of gravitational waves as the breakthrough of the year announced in the December 2016 issue [Adrian Cho. The cosmos aquiver. Science. 354:1516, 2016]. Alternatively, another poll (of readers) listed the gravitational wave by the LIGO interferometer as number two, preferring as number one the breakthrough in tissue culture techniques that allow human embryos to be sustained ex vivo for nearly 2 weeks. The “people’s choice” for number 3 was portable DNA sequencers, followed by an artificial intelligence milestone for number 4, and a finding on cell senescence and aging. My point is that human biology was central to 4 out of 5 of the 2016 breakthroughs and will likely be prominent in the 2017 choices.

 

Eight.
December first, looking back, is noteworthy for historic airplane crashes. As the methodology of aviation checklists has been imported into medical practice, most visibly in the surgical arena, it is useful to cross-examine failures and successes in both fields. Two aviation disasters occurred on this particular day in 1974. TWA 514 crashed northwest of Dulles Airport killing all 92 on board. En route from Columbus to Washington National Airport (now Reagan) the plane was diverted to Dulles due to high crosswinds and slammed into the west slope of Mount Weather. Terminology discrepancy between flight crew and controllers, heavy down drafts, and reduced visibility from snow were blamed. U.S. Congressman Andy Jacobs, scheduled on that flight, had refused to pay a $20 seat upgrade and luckily took another plane. The same day, Northwest 6231 crashed near Stony Point, NY, killing only the three crew members flying the plane from JFK airport to Buffalo as a charter to pick up the Baltimore Colts, whose planned aircraft was grounded in Detroit by a snow storm. Failure to activate the pitot tube heater, presumably a checklist item, was the root cause, resulting erroneous airspeed readings, icing, and a stall. Both planes were Boeing 727s.

On this day in 1981 Inex-Adria Aviopromet Flight 1308, a Yugoslavian charter McDonnell Douglas MD-81 from Brnik Airport in Slovenia, crashed on approach to Ajaccio on Corsica. Air traffic control believed the plane was in a holding pattern over the sea and requested it to descend, although it was actually 9 miles inland. The crew knew the plane was over the island and was surprised at the instruction to descend from their holding pattern, repeating their uncertainty to ground control. Ajaccio Airport had no radar and flight controllers insisted on descent which took the plane right into Mont San-Pietro killing all 180 people on board. On investigation, communication confusion was named as main factor.

Coincidentally a few years later, on this particular date in 1984, NASA conducted the Controlled Impact Demonstration at Edwards Air Force Base, deliberately crashing a Boeing 720 flown remotely so as to study occupant crash survivability. (Picture below, Wikipedia.) Planes seem to be made more safely, but the human factors of miscommunication and deviation from routine procedure remain our Achilles heel.

 

Nine.

As the urology chair search process unfolds many people will be engaged in trying to figure out the best fit for our department. Academic medicine seems to have convoluted the process of leadership succession, but it need not be difficult. A reasonable chair candidate should be someone who can take a team from good to great. A good candidate has a track record of excellence and national respect in his or her field, particularly in the essential deliverable of the department. Chairs who have failed nationally never passed these two bars.

The key requirement of a chair is to deliver the main functionalities of the department and enhance its essential deliverable. For us, that key deliverable is state-of-the-art clinical care in all domains of urology and with accessibility for anyone in Michigan or beyond who seeks our services. The essential deliverable is the milieu for our foundational responsibility of educating the next generation of urologists and urology health care workers trained in urology. The essential deliverable is also the stimulus and laboratory for our mission of discovery and research. A chair must retain and recruit excellent faculty and staff to build stability and depth of the department’s critical units, while helping its people develop their careers and fulfill their aspirations.

Personal traits of kindness, moral center, integrity, trustworthiness, flexibility, high emotional quotient, and humor are important. These are difficult to ascertain in external applicants, while a few minor deviations noted over decades of interactions “in the trenches” can derail internal candidates. Intellectual ability to deal with stress, complexity, and ambiguity is necessary. A successful chair needs curiosity to keep up with urology, medicine in general, and the changing world as he or she guides a department. A personal sense of cosmopolitanism builds the diversity, equity, and inclusion necessary for a great team.

A number of organizational talents are critical. The chair must understand and articulate the mission of the organization, sharing its beliefs and values. The chair must listen well and understand the department’s stakeholders. The chair must build teams, develop consensus, elicit a vision, and craft strategies with stakeholders. The chair should be a proven hands-on problem solver when necessary, yet be an excellent delegator. The chair must understand the social responsibility of the organization relative to its partners, community, region, nation, and world-at-large. A chair must steward and grow the departmental resources. I came to learn these attributes from leaders of my various career stations and particularly from dean Allen Lichter and coach David Bachrach.

 

Ten.

What lies ahead. It may seem doubtful that many people will be talking about “the halcyon days of 2017” next year or beyond, yet who knows what lies ahead to reframe our perspective? Historians viewing certain domains such as Astros baseball, might indeed think 2017 was a golden, happy, and joyful time. Turbulence in the health care markets, the uncertainties of regulations such as MACRA, changing demographics, expanding comorbidities, domestic violence, and environmental deterioration may combine to make 2017 look better from the rear-view mirror than it seems now from our perspective in December of this year.

Secular stagnation, an idea proposed by American economist Alvin Hansen in 1938, suggested that economic progress after the Great Depression was restrained as investment opportunities were held back “by closing of the frontier and collapse of immigration” [Economist Aug 16, 2014]. The idea could be expanded to the thought that any great shock to the world-at-large is followed by a period of latency. One can only guess how historians someday will define the era in which we are presently immersed. Stagnation of human progress is evident in many parts of the world, encompassing diplomacy, human rights, food security, personal safety, health care, environmental quality, as well as economic growth. If one views the world through a dystopia lens, then tomorrow’s metaphorical glass is half empty and this year may be viewed as relatively halcyon. With a more optimistic lens, if human progress ultimately wins the day, as history indicates, the year 2017 may not appear particularly halcyon.

This year ahead will be busy for the Department of Urology at the University of Michigan. A search committee for new chair begins with strong representation from our department. John Wei, Kate Kraft, and Scott Tomlins know our department well, and the other members of the committee are terrific choices as well. Our departmental retreat, April 14, will be a good time to take stock of the process. A special meeting on bladder cancer, the Teeter Symposium, is planned for May 4. Bob Teeter, a friend of our department, lost his life to bladder cancer a decade ago and since then knowledge of the biology of this disease had advanced greatly, as have surgical and medical treatments. The symposium will be an opportunity to see how far we have come and develop some paths for the future. We look forward to the Nesbit Reception at the AUA in San Francisco, Sunday, May 20. During the Ann Arbor Art Fairs, we will host the 12th Chang Lecture on Art and Medicine on July 19 and the next day will feature Hadley Wood of the Cleveland Clinic as the Duckett Lecturer and Rosalia Misseri of Riley Children’s Hospital in Indianapolis as the Lapides Lecturer. Our Health Services Research Symposium will be September 13 and 14. The Nesbit Alumni Society meeting September 20-22 will feature our own alumnus Toby Chai, now professor of urology at Yale. The Montie Uro-oncology Lecture is planned for some time next autumn. In 2019 we begin centennial celebrations to transition into the second century of urology at the University of Michigan.

 

[Neighborhood leaves, in transition, 2017]

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

November matters

DAB What’s New Nov 3, 2017

3742 words

One.
The matula, an historic symbol of the medical arts and title of this electronic periodical, was the transparent beaker used to examine urine in the pre-scientific days of health care, as people sought explanations for and expectations from their illnesses. Fear and uncertainty exacerbate human illnesses and our earliest prehistoric ancestors found comfort from their fellows in clans and caves to care for and sometimes heal them. The matula is a useful metaphor for the acts of looking, listening, and examining evidence to discover what really matters in clinical situations.

In ancient days what really mattered to people with illness or injury were the issues of treatment and prognosis: what can be done to help, what comes next, will I live, or will I die? The specific matter of diagnosis was most likely subsumed by the idea of what caused the problem. Gods, fates, cosmic forces, evil-doers, bad luck, or obvious injury were likely culprits before germ theory, organ-based dysfunctions, or other explanations based on a verifiable conceptual basis of health and illness. A sense of prognosis, however, was of practical value.

Uroscopists inspected urine for color, consistency, clarity, sediments, smell, and sometimes taste of urine, to find clues for treatment and prognosis. This was not illogical. Pink urine from infection or trauma might be followed by recovery. Gross blood and particulate sediments would suggest recurrent bladder stones. Scanty concentrated urine from dehydration might signal severe gastroenteritis and a grim prognosis. Uroscopy grew into a complex pseudoscience with fanciful claims of prognostic significance based on intricate characteristics of urine samples. Newer tools, such as the stethoscope and microscope superseded matulas and the future will bring better tools.

Thoughts about the future occasionally slide into dystopian visions and invite the question: what really matters to each of us? Putting aside occupational questions of healthcare professionals (making a diagnosis, ascertaining a treatment), political ideology (conservative or liberal, R or D, libertarian or socialist), or pragmatic issues (where do I live, what car do I drive, what’s for lunch?), we each have our own beliefs, although ultimately most people share similar fundamental desires for safety, comfort, and peace of mind. Family and friends matter.

We cherish personal liberty, physically and intellectually. Beauty, curiosity, and clarity matter. Social matters are important to most people; kindness, truth, integrity, respect, belonging, and sustainability are essential in a civilized world. The last item may seem a bit out of place, but as we sustain health, welfare, independence, and safety, for ourselves, our families, our communities, and our descendants, by simple logic we need to sustain our environment.

 

Two.


With Michigan’s gorgeous autumn colors fading in the rear-view mirror, November’s matula brings Thanksgiving into sight and notably the iconic holiday images of Norman Rockwell. His Four Freedoms paintings, based on Franklin Roosevelt’s State of the Union Address in 1941, illustrated the freedoms that FDR thought mattered greatly: freedom of speech, freedom of worship, freedom from want, and freedom from fear. These freedoms extended the sense of the liberty entrenched in the second paragraph of the Declaration of Independence.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness, – that to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, …”

Roosevelt’s four freedoms are more specific than the liberty mentioned in The Declaration at the dawn of the Revolutionary War, although political liberty was not far from Roosevelt’s mind when he gave the speech 11 months before the U.S. entry into World War II. The speech also slyly broke with America’s non-interventionism, by advocating support for our allies already in armed conflict. The words of Roosevelt and paintings of Rockwell mattered greatly to Americans in the 1940’s and they seem to matter now in this new century. Rockwell’s Four Freedoms paintings appeared in the Saturday Evening Post in 1943 and were used in war bond posters and postage stamps.

Rockwell also painted enduring images of healthcare professionals, some modelled on his neighbor Dr. Donald E. Campbell. After this topic was discussed in previous pages of WN/MT (March 4 & May 6, 2016) the doctor’s great granddaughter, Moira Dwyer, kindly sent us information and photographs that the family kept. Dr. Campbell, born in 1906, graduated in 1939 from Middlesex Medical School and practiced in Stockbridge, Massachusetts providing nearly the full spectrum of medical care to his community. He retired at 83 and died in 2001 at 95. Like the English physician, John Sassall, detailed in John Berger’s book, A Fortunate Man, Campbell was an indelible part of his community, providing far more than clinical services for patients by going beyond the specificity of medical conditions of his patients to understand their co-morbidities, inner needs, and social constraints. [Matula Thoughts Oct, Nov, Dec. 2016 & Feb. 2017]

As a footnote to Dr. Campbell, Middlesex College of Medicine and Surgery was founded in 1914 in East Cambridge, Massachusetts and was affiliated with a hospital of the same name. The campus moved to Waltham in 1928 and by 1937, it also included schools of liberal arts, pharmacy, podiatry, and veterinary medicine in addition to its school of medicine. Accreditation by the AMA became problematic, ostensibly due to issues of funding, faculty, and facilities although many claimed the merit-based admission policy and unusually diverse student body of Middlesex grated on the far more homogeneous American medical establishment at mid-20th century. Medical schools then maintained ethnic and religious admission quotas and Middlesex was an unabashed outlier with its diverse student body. In 1946, the Middlesex trustees transferred the charter and campus, with the hope that the medical and veterinary schools would be continued, to a foundation that created Brandeis University two years later. Middlesex Medical School did not survive the transition to the new university.

 

Three.
It is a profound community asset to have a Campbell or Sassall and it is impossible to fully measure their impact as a citizen, leader, mentor, and role model. These essential anchors of society bring not just their professional skills, but also their values, leadership, and expectation of fairness to a community. They look out for the common man and particularly for the most vulnerable members of the community. It is no coincidence that a universal ploy of anarchists, revolutionaries, and authoritarian pretenders as seen widely across the planet, is assassination of these “honest brokers.” The moral example and leadership of doctors such as Campbell and Sassall is our ultimate expectation for the medical professionals we teach. These mentors and role models act as epigenetic factors for the larger “superorganism” of humanity. They are operational factors between human genetics and civilization.

Education and training of physicians changed since 1939 when Campbell graduated medical school. The 4-year curriculum deepened with the growing scientific basis of biology and disease while graduate medical education (GME) also expanded with enlarging technology and new specialties of health care. The period of residency practice and study is now the career-defining facet of a doctor’s learning. Nearly 80 years since Dr. Campbell’s graduation, medical students enter fields of GME in as many as 150 areas of focused medical practice with learning experiences that may exceed twice the years the trainees spent in medical school.

Healthcare education differs from that of lawyers, engineers, and most other career paths. Physicians, pharmacists, nurses, and dentists require an immediate educational context of patient-care. The University of Michigan recognized this fact in 1869 when it converted a faculty house into a hospital, thereby becoming the first university to own and operate a medical center. We recognized this anew when we began to create a wider health care network, in the past few years, capable of supporting our large educational mission, now educating 900 MDs and health care PhDs, 1100 residents and fellows in medicine, as well as dentists, nurses, and pharmacists. One could easily argue that universities should offer a wider coherent educational milieu. A grander educational vision to include all parts of the health care workforce (physician assistants, surgical scrub technicians, medical assistants, etc.) would have a great effect on state economy and on our workforce pipeline. It could be done with robust partnerships not only with the UM Flint and Dearborn campuses, but also with our adjacent and regional community colleges.

 

Four.
In its more rudimentary days, the UM academic health center was distinguished by its implementation of  fulltime clinical faculty, terminology indicating that physicians who practiced or taught exclusively within a teaching hospital had a fulltime salary independent of their patient care revenue at that site. In the early days of UMMS this model attracted national luminaries such as Charles de Nancrede in 1889 and Hugh Cabot in 1920. de Nancrede was an attending surgeon and clinical lecturer at Jefferson Medical College, among other Philadelphia medical institutions, and was a major name in American surgery as a clinician, teacher, and pioneer in antiseptic and aseptic technique. At Michigan he presided over the construction of the new West Hospital in 1892, established a world-class surgery department where he practiced exclusively, and wrote an influential textbook of surgery. [World J. Surg. 22:1175, 1998.] Cabot was an even more stellar addition, coming from Boston as an internationally known urologist, where he had become disillusioned by the monetary nature of medical practice.

The world of healthcare practice, education, and investigation is different in the 21st century. The few academic medical centers that will survive well in the future will be those with the best and brightest geographic fulltime faculty, the majority of whom will be busy clinicians. Their milieu may well depend upon robust clinical productivity that brings the most challenging clinical problems to them and their facilities, but this will also require a very substantial volume of more routine clinical work as the context for education of all learner groups and clinical trials, in addition to inspiring basic science investigation. This clinical milieu will require a robust array of endowed professorships to give faculty a modest disconnect from clinical practice to allow teaching and academic work.

 

Five.

Fellow professionals. Modern specialty-based health care has shifted emphasis from individual all-knowing utility-player doctors like Campbell and Sassall to large teams that deliver their parts of today’s healthcare. The knowledge base, growing list of specialties, and technology of medicine today is so great that the centrality of a single physician is a model that no longer works well for health care delivery. Furthermore, linguistic confusion arises as other terms are awkwardly deployed to indicate all healthcare providers (not just physicians) more inclusively. This matter became acute as we have been creating bylaws for our new University of Michigan Medical Group (UMMG). A good nomenclature solution arose from Gerald Hickson, a Vanderbilt pediatrician (above), speaking to the UMMG this summer about programs that build professionalism and create a culture of safety. His phrase, fellow professionals, nicely includes MDs, DOs, nurses, PAs, physical therapists, podiatrists, occupational therapists, optometrists, respiratory therapists, pharmacists, medical assistants, etc. [Hickson et al. A complementary approach. Acad. Med. 82:1040, 2007]

 

Six.
Medical professionals are under stress today from many sources, but the idea of a career in medicine still drives some of the best and brightest young people into our work, as judged by the medical school and urology residency applicants we see each year. I’ve just read applications, personal statements, and letters of recommendations from nearly 70 candidates for our 4 positions to start next July, and again I am blown away by the breadth and depth of these fourth-year medical students who will, all too soon, become our successors as urologists. They will have to resist the pressures to commoditize, corporatize, and industrialize their work as the 21st century rolls along. The electronic record is one of the pressures. A paper in Health Affairs last April surveyed primary care physicians and found they spent 3.17 hours on computers (desktop medicine) for every 3.08 hours spent with patients. [Tai-Seale et al. Electronic health record logs. Health Affairs. 36:655, 2017.]

It is impossible to predict the world that will envelop our successors. The conceptual basis they will learn and the skills they acquire are merely momentary assets. Ideas and techniques will change as long as human progress continues. The values, mores, social skills, curiosity, imagination, and ultimate kindness of our successors will be the principle assets to distinguish their careers, their effects on their communities, and their value to society in general. The influence of their ambient role models is as important as the book-learning and clinical skills imparted in graduate medical education. The epigenetic nature of values, mores, social skills, and role models show us, our colleagues, and our successors how and when to deploy the vast stores of information and skills we have accumulated. Just as importantly, some among them will be inspired to discover new knowledge and develop new skills.

 

Seven.

With Thanksgiving coming up, I’m appreciative for precarious and relative world peace, food security, respite from climactic disasters, and the happy, healthy, lives we may have. [Above: Jennie Augusta Brownscombe, The First Thanksgiving at Plymouth, 1914, Pilgrim Hall Museum, Plymouth, Massachusetts.] The great minds who have made this world so interesting are another blessing, people who looked at the world with clarity to make observations or find patterns that escaped everyone else at their moments.

The name, Conrad H. Waddington, probably doesn’t spring to mind, but is worth consideration. Born on a tea estate in Kerala, India, around this time of year in 1905 this British developmental biologist introduced the concept and word epigenetics. At age four he was sent off to England to live with family members while the parents remained at work in India for the next 23 years. In England, a local druggist and distant relation, Dr. Doeg, took the boy under his wing and inspired his interest in sciences. At Cambridge, “Wad” took a Natural Sciences Trips (a flexible curriculum across sciences) and earned a First in geology in 1926. With a scholarship he studied moral philosophy and metaphysics at university, assumed a lectureship in zoology, and became a Fellow of Christ’s College until 1942. During WWII he was involved in operational research for the Royal Air Force, and in 1947 became Professor of Animal Genetics at the University of Edinburgh where he worked for the rest of his life except for one year at Wesleyan University in Connecticut. Waddington’s landmark paper in 1942 begins with four lovely sentences.

“Of all the branches of biology it is genetics, the science of heredity, which has been most successful in finding a way of analyzing an animal into representative units so that its nature can be indicated by a formula, as we represent a chemical compound by its appropriate symbols. Genetics has been able to do this because it studies animals in their simplest form, namely as fertilized eggs, in which all the complexity of the fully developed animal is implicit but not yet present. But knowledge about the nature of the fertilized egg is not derived directly from an examination of eggs; it is deduced from a consideration of the numbers and kinds of adults into which they develop. Thus genetics has to observe the phenotypes, the adult characteristics of animals, in order to reach conclusions about the genotypes, the hereditary constitutions which are its basic subject-matter.” [Waddington. Endeavor. 1: 18-21, 1942]

Later on the first page he suggests the term epigenetics to encompass the “whole process of developmental processes” that carries genotypes into phenotypes. The influence of Dr. Doeg, whom Waddington called Grandpa, was no doubt significant. The specifics of Dr. Doeg eluded me as I read about Waddington. Too bad, because it would have been illuminating to understand the nature of the fruitful mentorship that shaped Waddington’s curiosity, lucidity, communicative skills, and sociability that left him a context to discover what he did.

 

Eight.

Black Bart, legendary stagecoach robber, committed his last robbery on this date in 1883. He specialized in Wells Fargo robbery, and it’s a bit ironic that the bank’s more recent history indicates it has internalized that larcenous bent to its own customers. Black Bart was actually Charles Earl Boles, variously known as Charley Bolton, a gentleman bandit in Northern California and Oregon. Born in Norfolk, England, he and his brothers joined the California Gold Rush in 1849. The brothers died and by 1854 Charles was married and living in Decatur, Illinois with a wife and four children. After serving in the Civil War he returned to California and gold prospecting in 1867, leaving his family behind. In 1871 Bolton wrote his wife and described an unpleasant encounter of some sort with Wells Fargo & Company agents and vowed revenge. He fulfilled the vow, adopting the name Black Bart, and robbed at least 28 coaches in California and Oregon, although never fired a weapon or harmed anybody. The last known robbery was in Calaveras County, between Copperopolis and Milton, when he was wounded in the hand while escaping. Detectives found personal items at the scene and through laundry marks traced a handkerchief to a San Francisco laundry on Bush Street. They quickly located Boles, living in nearby boarding house, and convicted him of the November 3 robbery.

Black Bart served four years at San Quentin and after release he was constantly shadowed by Wells Fargo detectives. In a letter to his wife he said he was tired of the attention, and disappeared after being last seen near Visalia on February 28, 1888. A distinctive feature of Black Bart was that he was consistently a gentleman, always polite and never using profanity. It might be said that he was a rare and exemplary professional in his business, living according to his values. His sense of mission will never be exactly known to us today, but Black Bart was somehow compelled to right some perceived wrong and, like most of us, he needed an income so Wells Fargo was a fitting opportunity.

Even in his risky occupation Black Bart remained kind and harmless, other than theft from a corporate entity of questionable kindness itself, it turns out. If he could act kindly in spite of living on the edge as he did, health care professionals such as us might consider him as a role model, although somewhat of a peculiar one. Somewhere along the line he must have had the parenting, mentorship, or experience that built his character of kindness, larcenous though it might have been. [Above book cover. Black Bart: Boulevardier Bandit. George Hoeper. Word Dancer Press, 1995]

 

Nine.

Jack Lapides. As we unearth stories of Michigan Urology, colorful anecdotes come to light and many involve Jack Lapides. The personal story of a patient who underwent a life-changing Lapides vesicostomy was told on these pages in July and that gentleman was ultimately laid to rest in a ceremony at Arlington in August. Another story from a former medical student was that of Jack teaching the students the art of cystoscopy when he would ask the students to peer over his shoulder and look through the scope to describe what they saw.

It is said that Lapides sometimes mischievously disconnected the light source cord as someone leaned in to look and occasionally an uncertain student provided a fanciful description of the dark or black field. This may have been one origin of his Black Jack moniker, although just as likely it might have been related to the fear he struck among rookies in his expectation for high standards and excellence. Dr. Lapides’s conferences were legendary. He was exacting and tough, requiring that all presentations be stripped of jargon and abbreviations. The IVP, for example, was intravenous pyelogram. Conferences today are more causal. The tradition of teaching conferences persists, but on a larger canvas since Lapides’s days with 4-5 faculty, our scale having increased by a factor of 10. Just below is Thursday morning Grand Rounds. Further below is the Friday AM Mott imaging conference that follows a formal review of operations scheduled the following week. In both instances we have outgrown our rooms.

Yet another Lapides anecdote turned up last week when I was at the American College of Surgeons (ACS) meeting and spent an evening with Lou and Ginger Argenta (below: with Tony Atala of Wake Forest, in San Diego October, 2017).

Lou had been our plastic surgery head in my early years at Michigan and innovated, with Michael Morykwas at Wake Forest, the Vacuum-Assisted Closure (VAC) device, a paradigm-changing system to manage burns and wounds. For this he won the Jacobson Innovation Award from the ACS in 2016. Lou recalled how Jack Lapides, in his retirement years, took up welding and small engine repair, learning and teaching them at Washtenaw Community College. Jack kindly performed a welding repair on the broken bicycle of young Joey Argenta, and the work held up for years of further bicycle abuse.

Lapides stories will undoubtedly continue to emerge. The man and his work had a long reach.

 

Ten.
What really matters to us, to our patients, to our colleagues, to our community, and our 7 billion global brethren is a deep question usually lost in the daily hustle of life. Most people have roughly similar ideas about what matters, although each has a particular take on things. Donald Campbell, Charles de Nancrede, Charley Bolton, Jack Lapides, Dr. Doeg, CW Waddington, FDR, and Rockwell had their particular world views that shaped their legacies. All, no doubt, shared many of the things that mattered to them, although each likely ordered and interpreted those characteristics idiosyncratically, perhaps Black Bart most peculiarly.

It is no accident that the four essential freedoms that Roosevelt identified have a strong basis in health care. Freedom from want is most obviously tied into food security, but it could just as easily be interpreted as freedom from needs that rationally include shelter and health care. Freedom from fear was illustrated by Rockwell as a fear of illness, but safety and personal security could just as easily have been the visual that Rockwell used. Liberty in the political sense is not so far from liberty in its mobility sense. An authoritarian regime may enforce curfews or travel restrictions, just as health conditions restrict people from being out and about to participate fully in society. If governments are to promote life, liberty, and the pursuit of happiness, the four freedoms are essential.

Human values and role models are the factors that translate human beings into the superorganism of human civilization. Those factors can go the way of apoptosis or can epigenetically build a prosperous, just, beautiful, robust, and sustainable version of itself for the next generation.

[Autumn foliage, my neighborhood 2017]

 

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

Gratuitous thoughts for October, 2017

Matula Thoughts Oct 6, 2017

3855 words, 31 pictures

 

 

One.

Every business has its seasons and the fall is primetime for academic medicine and other occupations. While we are reluctant to see summer slip away, autumn brings excitement and new energy. Entering medical students accommodate to a new learning environment, seasoned students consider career selections and their Step 1 exam, and senior students are consumed with the residency match. [Above: first year medical students at lunch in July on their first day.] Similar anxieties play out for residents although the intensity and duration of years usually exceed those of medical school. Exams don’t go away in residency, for the residents and fellows contend with yearly in-service tests and ultimate board certification processes. New faculty undertake “on-boarding” processes as they step out into the mature and most demanding phases of their careers.

Faculty teach and mentor intensely in the autumn and show their academic stuff at professional meetings, all while fulfilling the 24/7 demands of healthcare. Many faculty also have deep research commitments that bear the intellectual fruit we expect will make tomorrow’s health care better than that of today. Faculty, too, contend with promotion expectations, board recertification examinations, and the insane administrative on-line mandatory expectations required of them. Somehow our faculty get all this done, and done very well in comparison to other medical schools and academic health centers.

The 24/7 health care cycle is relentless. Our Department of Urology provides care throughout 16 clinical sites and 9 surgical locations, held together by a first-rate administrative team with Malissa Eversole, Marleah Stickler, Kandy Buckland, Tammie Leckemby, and of course Sandy Heskett. Jack Cichon, with our inaugural Urology Chair Jim Montie, set the pace for this excellence. Monica Young leads the Call Center that, with our administrative staff, coordinated 42,041 clinic visits, with 12,639 new patients and 6,426 operative procedures for our clinical faculty last year. The UM health system, Michigan Medicine, is growing and changing our regional profile as well as the local environment “on the hill.” The lovely view seen below,  over open space created at the old Kresge Laboratory site, will disappear when a new patient tower assembles on this site.

 

Autumn academic meetings and the written medical literature that springs from them display much work from the faculty and alumni of the University of Michigan Medical School. Our Urology Department provides a heavy presence at all relevant urology professional meetings this season and contributes significantly to Michigan’s “academic product,” thus furthering the mission, vision, values, and strategy of Michigan Medicine. At this time of year amidst the dense shop-talk at professional meetings in medical specialty meetings, Michigan football talk enlivens conversations.

 

Two.

A field trip to Chelsea Milling Company last month showed us how another business stays ahead in challenging times. Autumn and winter are prime baking season, according to the company president Howdy Holmes, so Chelsea Milling’s products need to be well-stocked in grocery stores throughout 50 states and 32 other countries.

Chelsea Milling has weathered many changes in its competitive markets, making Jiffy Mix since 1930 with a dominating market share in muffin mixes and entering a busy season as we do. Our tour revealed constant innovation throughout Chelsea Milling in production, employee satisfaction, quality, safety, packaging, and distribution, with lessons for our work in Michigan Medicine. A strong workforce aligned around mission, vision, and values combined with enlightened leadership creates quality products, a pleasant workplace, stakeholder satisfaction, and a durable business. We found it all comes down to the team.

[Above: DAB, Paholo Barboglio-Romo, Lindsey Herrel, Courtney Shepard, Miriam Hadj-Moussa, Howdy Holmes. Below 2 pictures: first home game from Martin family seats.]

Sports metaphors work well in business and health care discussions. Belief in teams, mutual support, practiced fundamentals, creation of plays, discovering opportunities, striving for excellence, relishing victories, learning from defeats, while educating successors, are universal attributes of successful social endeavors. Michigan’s athletic teams provide life-changing environments for thousands of students each year, and these students will bring the skills, disciplines, habits, and leadership they learn from their sports to the teams of their ultimate careers. It is a happy accident that most modern universities incorporate athletic teams along with other performance arts such as music, theater, law, engineering, nursing, pharmacy, and health care. The Schembechlarian admonition to attend to “the team, the team, the team” pertains to nearly everything we do and teach at Michigan. Michigan football, however, is probably our university’s most universally-acknowledged product and it brings a shine to everything else on our campus, especially in winning seasons.

The Nesbit Alumni Society of our Urology Department links its yearly reunion to football games, this year coinciding with the victory of Air Force. Just as every profession has its rules and standards, each sport has its mores – its customs, practices, and values. Overarching the peculiarities of each sport, a sense of fair play transcends most activities, more so in college than professional sports. Fair play pertains in academic medicine as well, where each specialty and local medical center have their own cultural rules and expectations, but overarching expectations of fairness and integrity apply, thereby restricting discrimination, plagiarism, deceit, substandard work, and self-serving behavior. Breaches of trust are naturally inevitable in human society, especially when temptations are great, but this is where character is discovered. Intercollegiate sports and graduate medical residency training are excellent crucibles to discover and build character.

 

 

Three.

Residency training and intercollegiate sports share many features of education, coaching, and team-building. Visiting professorships to openly share best practices among “competing” centers, however, are strong traditions in chiefly in health care. Michigan’s former chair of Internal Medicine, Bill Kelly, urged his faculty to bring in thought-leaders and innovators to their divisions each year to speak and challenge residents, fellows, and faculty themselves. This added expense of multiple visiting professors is offset by robust clinical productivity by faculty and philanthropic gifts that put dollars on the table for this type of education.

Carl Olsson (below), former chair at Columbia, was visiting professor for us in late August, discussing “A new prostate cancer biopsy reporting system with prognostic potential.”

The Weisbach Lectureship in Prostate Oncology brought Peter Carroll, Chair of Urology at UCSF, to Ann Arbor in September to discuss “Active Surveillance for early stage prostate cancer; should we be expanding or restricting eligibility?” This lectureship (above) was started in 2002, in memory of Jerry Weisbach, pharmaceutical innovator and friend of the University of Michigan. [Below: Arul Chinnaiyan, Peter Carroll, and Ganesh Palapattu]

 

Four.

The Nesbit Alumni Society Reunion took place in mid-September. Initiated in 1972 by John Konnak in honor of Michigan’s first Urology Section Chief, the Society met for three days including the football contest with Air Force. John Konnak was a bedrock of the Michigan Urology training program when Ed McGuire came as section chief in 1983. John had an MD with AOA distinction from the University of Wisconsin, internship at Philadelphia General Hospital, U.S. Public Health Service experience in Arizona, and a year of surgical residency at UCLA’s Harbor General Hospital. He came to Ann Arbor to train with Nesbit and completed the residency program in 1969 under Jack Lapides. Every resident who trained under John benefited from his work ethic, humor, and high expectations. John was a respected citizen of the Medical School Community and was an early participant in Ethics Committee. The photo of the first adrenalectomy for Conn Syndrome standing with Dr. Conn and looking over Nesbit’s shoulder in the operating room is one of the great images of Michigan Urology.

John’s paper with Joe Cerny, “The surgical treatment of Cushing’s Syndrome,” remains a classic. [J. Urology 102:653, 1969] John passed away in 2011, but his wife Betty (below) remains an enduring supporter of our department and a steadfast presence at Nesbit meetings.

In two years (FY 2019) the Nesbit Society meeting will kick off the Centennial Year for Michigan Urology, if we view the initiation of world-class urology practice, education, and research with the arrival of Hugh Cabot in Ann Arbor in 1920. Cabot came from Boston where he had grown up, practiced surgery, and became a world-renown specialist in urology. His two-volume text, Modern Urology, helped define the field, previously known as genitourinary surgery. After overseas duty in WWI he was unchallenged by Boston’s private practice environment at the time, and came to Ann Arbor as chief of surgery in 1920, rapidly becoming dean of the University of Michigan Medical School (UMMS). His first 2 residents were Charles Huggins and Reed Nesbit. After Cabot was fired by the Regents in 1930 (“in the interests of greater harmony”) Nesbit became inaugural head of urology in the Surgery Department. Our Medical School had no dean for the next several years and was run by the school’s executive committee, although Cabot’s name and picture mysteriously remained on the Medical School class pictures through 1932, as noted here last month. Cabot completed his career at the Mayo Clinic, then led by his friend William Mayo (UMMS class of 1883), while Nesbit went on to grow the urologic clinical, educational, and research programs of the University of Michigan for the next 38 years. [McDougal et al. Urology 50:648, 1997] Although we could have been called the Cabot Society, Konnak’s choice of the Nesbit Society is the better fit.

 

Five.

Laymen often wonder what’s the big deal about medical societies. A friend often teases me about my professional meetings he calls “boondoggles.” My introduction to medical meetings began when I was a surgical resident at UCLA and faculty propped me up for presentations to local gatherings of the American College of Surgeons in San Diego, Napa, and Palm Springs. My awkward presentations at those times are pale by comparison to the poised and self-assured presentations our Michigan students and residents give today. For a beginner, the opportunity to get one’s head around a topic, present it to the “elders” in one’s field, and respond to questions is an important step in professional development.

My friend understands that healthcare is a social business. It takes teams, and today those teams are big. The knowledge and tools of healthcare evolved socially across generations through practice, discussion, observation, reasoning, experimentation, disappointment, success, insight, new ideas, criticism, refinement, innovation, and more discussion. These are the social tools of human civilization, working through mentorship, schools, guilds, organizations, and specialty practices. Urologic societies and academic departments came on the scene in the late 1800’s and continue to be the primary marketplaces for new ideas, leadership development, and talent spotting.

The University of Michigan’s North Campus Research Complex (above, Building 18) was the venue for the Nesbit academic sessions this year. This property was the site of the Warner-Lambert Park-Davis research center, later taken over by Pfizer. Lipitor was developed here. The company announced plans to vacate the property in 2002 and eventually sold it to UM, with clinical departments of the Medical School bearing a little under 80% of the costs, which for the purchase and deployment over 10 years was around $325 million. Since we assumed occupancy in 2010 most space is occupied, including significant urology presence with Dow Health Services Research Division, and laboratories and teams of Mark Day, Evan Keller, plus Arul Chinnaiyan and Scott Tomlins, of the Pathology Department. David Canter (below) presided over the space when it was Pfizer and recently our NCRC Executive Director.

 

Six.

The Nesbit scientific program was superb, organized by President Mike Kozminski and Secretary/Treasurer John Wei and implemented by our administrative team. The large space at NCRC dwarfed our 60 plus attendees, but was an hospitable environment. Bob Uzzo (below with former Cornell co-resident John Wei) from Fox Chase Cancer Center gave two world class talks.

Alumni networked with our present departmental faculty and trainees.

Jay Hollander, above with David Harold and Len Zuckerman (Nesbit classes 1984, 1978, & 1980), donated the famed Nesbit plaster prostate models in honor of Gary Wedemeyer, who attended with his wife Nola (below). Dave, gave our department some antique cystoscopes that we hope to place in a visible time capsule for our 2020 Urology centennial, along with the Nesbit models.

Mario Labardini (Nesbit, 1967) travelled from Texas and Tom Koyanagi (Nesbit 1970) from Japan gave excellent presentations, Mario (below) on an extraordinary historical intersex case and Tom on his innovative hypospadias operation that left a great mark in pediatric urology.

Below you see Tom between Adam Walker, new clinical assistant professor with our West Shore Urology group in Muskegon, and Ted Chang (Nesbit 1996), one of his residency teachers at Albany’s urology program under Barry Kogan (Nesbit 1981).

John Allen (below), from our Gastroenterology Section of Internal Medicine spoke on health care as a generality and a current political hot-button, discussing as either a basic human right or commodity. (Below)

The Ted and Cheng-Yang Chang (Nesbit 1996, 1967) along with Mike and Michael Kozminski (Nesbit 1989, 2016) were our two father-son Nesbit urology pairs in attendance (below).

Below you see residents and students admiring Nesbit’s teaching models and considering how different their learning of prostatic surgery is today with video systems, lasers, etc.

Dinner at Barton Hills amplified social opportunities with our treasured Nesbit alumni, Nesbit lecturers, faculty, residents, and families. The Koyanagi family (below: Tom, Kiyoko, Sachi) travelled from Sapporo, Japan.

The tailgate at Nub Turner’s GTH Products preceded a win over Air Force, 29 to 13. [Above: Ghislaine deRegge, friend of Mario Labardini with Mark and Carolyn McQuiggan at Barton Hills Country Club dinner; Below Rita Jen, Olivia Hollenbeck, Mr. Hollenbeck, Amy Luckenbaugh at tailgate]

[Above: flyover by Blue Angels, captured on Sony Alpha 9, 24-240 lens, thanks to CameraMall]

 

Seven.

Nationally and globally things are not quite so tidy and progressive as seems to be true for us momentarily in Ann Arbor. Absent any superheroes to rescue the world, my personal expectations are modest. Before you tag this edition of What’s New/Matula Thoughts as cynical, let’s consider that particular attitude and its linguistics. Cynicism is a natural human protective responsive, with virtues as well as its obvious dark side. The attitude is often instigated when people feel as though their actions cannot solve immediate problems, or if their beliefs or stories are incompatible with a larger narrative or expectations, predicaments such as George Orwell described in his later works, 1984 and Animal Farm. The theater of health care discussions in Congress is a real-world example. So too is the incompatibility of the pressing environmental deterioration of climate, air, water, and land in contrast to the much political rhetoric.

A brief article in The Lancet earlier this year, “Cynicism as a protective virtue”, caught my attention. This two-page paper of 10 paragraphs took me a few readings to fully appreciate, but it was worth the effort [Rose, Duschinsky, Macnaughton. The Lancet 389:693, 2017]. The authors acknowledge rampant cynicism in the healthcare workforce is a response to the subjugation of individual agency of clinicians to care for their patients to larger forces. These externalities to the doctor-patient relationship include mandated work-flow systems, revenue generation, service metrics, and abstracted audits. Cynicism, the authors say, is “the immune response and not the disease.” As clinicians try to care for their patients they need to discover a different way to practice. “This discovery is the lived negotiation of the distance between policy and practice.” Raw and untampered cynicism, the authors note, is destructive, investing cynics in negative outcomes and leading to indifference, fatalism, and burnout. On the other hand, they suggest that tempered cynicism (e.g. wry cynicism or thoughtful cynicism, for example) can be a strategic virtue creating a protective critical distance between the cherished personal caring and professional values, that led most people into health care professions, apart from the deforming reality of healthcare organizations and public policies. Strategically “alloying” cynicism to a thoughtful attribute can carry clinicians from the dark side to the good side, if we may evoke a Star Wars metaphor. Alloyed cynicism thus can be a self-care strategy to regain composure, humor, clarity, resilience, and collegiality. This alloyed cynic can be an intellectual superhero in the daily professional struggle against corporate healthcare.

 

Eight.

Academic Medicine is a medical journal that most urologists don’t inspect routinely. An article earlier this year from the UCSF Psychiatry Department was titled “Why medical schools should embrace Wikipedia” and explains how the medical school offered fourth-year students a credit-bearing course to edit Wikipedia. [Azzam et al. Academic Medicine. 92:194, 2017] The outcome was that 43 students made 1,528 edits and the 43 articles have been viewed nearly 22 million times.

The article intrigued me as user and a believer in Wikipedia. I have always liked dictionaries and encyclopedias and treasure the authority of the great classics like Encyclopedia Britannica, Oxford English Dictionary, and Stedman’s Medical Dictionary. Rapid evolution of new information, limitations of print publication cycles, as well as the cost, storage, and rapid obsolescence made a Wikipedia-like product inevitable. The democratic nature of Wikipedia’s content limits and accentuates its authority. I occasionally get soft criticism from readers of Matula Thoughts/What’s New when I reference Wikipedia. Most people assume the classic dictionaries and encyclopedias to be more authoritative, and mostly they were. However, as a former editor for Stedman’s Medical Dictionary, I am still haunted by an error of my own in one edition. We are also aware that revisionist history, propaganda, and stereotype perpetuation existed in many authoritative definitions and narratives of the past. Although inaccurate and untruthful accounts can certainly enter Wikipedia, the crowd-sourcing nature of the readership provides a healthy mechanism for ultimate corroboration, correction, or rejection. Faculty member Khurshid Ghani, when he joined us, noticed that Wikipedia had no entry for Reed Nesbit, so he set to work to create one that still stands. We should have more interaction with Wikipedia, perhaps creating a dedicated urological section that might rightfully appropriate the name WikiLeaks.

 

Nine.

Health care worldwide needs superheroes, but for now we can only turn to comic books for inspiration. Superman, the first larger-than-life figure in my memory, was introduced with the inaugural issue of Action Comics, 1938. Superman is shown above with Prankster who had no actual super powers, but used pranks and jokes to commit crimes and foil superman. [Action Comics 1 (77) October, 1944. Cover artist Wayne Boring.] This is ancient ploy was revisited in a book by Paul Woodruff called The Ajax Dilemma: Justice, Fairness, and Rewards [Oxford Press, 2011]. Ajax, the superman of his Greek army, legend tells, was superseded for ultimate honors by King Agamemnon in favor of Odysseus who used clever tricks (e.g. the Trojan Horse) to win the day and capture Troy. The rejection drove Ajax, “the soldier’s soldier,” to self-destructive cynicism and insanity. The actual superheroes in my adult life are more in the mold of Odysseus as a great intellect and leader; Lincoln, Churchill, Eisenhower, E.O. Wilson, and Don Coffey to name a few. The last two, as great scientists transcend science as humanistic thought-leaders. Lacking any superheroes as of today in health care, I guess it’s up to us to make things better.

Argus, a lesser-known superhero in DC Comics, first appeared in 1993. This character was named after the many-eyed giant of Greek Mythology. The “eyes of Argus” was an expression that conveyed the idea that one was always under scrutiny in the real world as in the mythological world. That is, if your integrity and character waivered at any moment, to know that society was watching you, just as Argus watched his fellow mythological superheroes. Argus Panoptes, the giant of 100 eyes, was always on the alert because he could let many of his eyes sleep at any time, but the rest were wide open. Argus was the servant of Hera and she commemorated him in the peacock’s tail. [Below, Indian peacock, Wikipedia.] Argus persists as a name in a number of reptile species with eye-like patterns and it was once a popular name for newspapers. Wiki comes from a Hawaiian term for “quick.” Perhaps the better term for Wikipedia would be Arguspedia or the Argus Compendium.

 

Ten.

Cynics might say that nothing is new under the sun, a statement discounting both the promise of innovation and the value of history. It’s hard, for example, to reconcile that statement with photography where the technology has changed drastically. For me the shift from negative and slides to digital had the greatest impact. It was midway through 2006 when I belated entered the digital world. All my pictures up to then are in boxes of negatives, slides, and prints in the office and at home, impossible to totally reconcile in terms of inspection and conversion. Innovation is relentless and the century and a half since the daguerreotype has seen innumerable changes in equipment and media. Ann Arbor has its own history of photography with the Argus Camera Company, founded here in 1936 as a subsidiary of the International Radio Corporation.

The Argus C3 rangefinder had a 27-year production run and was a best-selling camera of the time in the United States. Argus was sold to Sylvania in 1959 and then generally slipped from sight, with occasional and transient rebranded products. The Argus building complex was sold to the University of Michigan in 1963 and then again in 1983 to First Martin Corporation and the O’Neal Construction Company that reopened it in 1987 with an Argus Museum now on the second floor. The museum has been generously assembled and funded by Bill Martin and Joe O’Neal, principals of the companies.

The Argus Model A, created and introduced in Ann Arbor in 1936 is said to have been the first entirely American made 35 mm camera. Visually resembling the iconic Leica camera, the Model A cost $9.95 and 30,000 were sold in the first week according to The Argus Museum, a lovely exhibition area in the second-floor lobby of the Argus Building Complex. While there you can find some key UM entities including Michigan Radio, a research division of our Department of Radiation Therapy, and Michigan Create. The International Radio Company that made the Model A had been established here in 1931 by local businessmen under the lead of Charles Vershoor as a countermeasure to the Great Depression and the main early products were table and floor radios, the Kadette and the International, as well as the first mass-produced clock radio conversion kit for cars. With the success of the Model A the company changed its name to the International Research Corporation and in 1938 introduced the Model C camera. The C2 and C3 followed, the latter becoming known as The Brick. More than 2 million bricks were sold over the next 28 years.

A 1947 patent design for a twin-lens reflex was the basis for the Argoflex (Argoflex Seventy-five – above). The company name changed to International Industries Incorporated in 1941, Argus Incorporated in 1942, and Argus Camera in 1949. Production shifted to gunsights, tank periscopes, optical fire control devices, and electronic aircraft controls for WWII and the Korean War. A company newsletter, much like What’s New and Matula Thoughts achieved wide distribution in the 1950’s. Argus cameras were seen in movies including The Philadelphia Story (1940), Watch the Birdy (1950), Smokey and the Bandit (1977, 1980), and Harry Potter and the Sorcerer’s Stone (2001), as well as TV shows such as I Love Lucy, Gunsmoke, Leave it the Beaver, Gilligan’s Island, and Columbo. This rich trove of information comes from the Argus Museum, created around the Don Wallace collection by Bill Martin and Joe O’Neal, now managed by the Washtenaw County Historical Society.

 

Thanks for travelling through this month’s Matula Thoughts.  (Nesbit prostate models above)

 

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

Dancers and Michigan’s third century

Matula Thoughts Sept 1, 2017

3866 words
Dancers & Michigan’s third century

One.

Summertime play draws to an end and work comes into sharper focus this September, as the University of Michigan enters its third century. Medical education’s academic season has been well underway for 2 months as now the rest of the University of Michigan comes back on line and takes up the challenge of examining the world anew. Autumn academic meetings lie ahead and our faculty become traveling salesmen for their ideas. History has shown that many big ideas in urology have come from Michigan and we anticipate many more are ahead. Nesbit urology alumni will reconvene in Ann Arbor this month for a scientific meeting and see the Air Force Academy play Michigan in football. [Above: Jacob Lawrence. Play, 1999. © 2017 The Jacob and Gwendolyn Knight Lawrence Foundation, Seattle / Artists Rights Society (ARS), New York]

Individual views of the world are shaped by one’s lenses and frames, literally and figuratively. Bob Uzzo, our Nesbit visiting professor this month, once sent me a picture of surgical loupes belonging to legendary Michigan Urology alumni, Ralph Straffon and Bruce Stewart, who had brilliant careers at the Cleveland Clinic. Crisp block letters identify the owners so we know who owned each one, but can only guess how the world looked to either of them. These two remarkable Nesbit trainees impacted hundreds of thousands of patients, thousands of students, and hundreds of trainees. They added to the progress of urology worldwide and both men cherished their Michigan origins and wore their Block M’s proudly. I was lucky to have known Ralph, but never met Bruce. Their photographs hang on the wall outside my office [Above glasses; below Ralph in center, Bruce upper left]. David Miller profiled Ralph for the Bulletin of the American College of Surgeons. [Miller DC, Resnick MI: Ralph A. Straffon, MD, FACS, 1928-2004, remembered. Bull Am Coll Surg 89:32, 2004.]

 

Two.

Block M’s. Pictures on our walls bring the past into focus on a daily basis and as you walk from the Main Hospital to the Cancer Center you can see the Block M on the Medical School diplomas, first as a font and later as a symbol. The class of 1861 (below) is the first in the lineup. No pictures of previous classes, going back to our origin in 1850, seem to exist. (A fire in 1911 destroyed the Medical School building with some of the original early pictures.) In 1864 an M-font vaguely resembling a block M is evident in the word “Michigan.” The first typical Block M (with serifs) appears in letters in the picture title, Departments of Medicine and Surgery in 1881. This occurs again in the text of 1883 and 1884, but is gone in 1885. Note that 1883 has 2 class pictures, the additional one being an informal one with the entire class sitting together. That additional picture was given by 1883 class member W.F. Mills to classmate William Mayo years later, in 1936.

The Block M became a deliberate symbol or logo in the Medical School 1923 class picture, with 29 faculty portraits contained within an M outline (below). Three other faculty (President Burton, Emeritus President Hutchins, and Hugh Cabot who was simultaneously dean, chief of surgery, and solitary urologist) share space outside the M shape and under the center.

The Block M tracing features faint extensions at the bottoms of the letter, called serifs, with squared edges as “blockish” as the M itself. Additional “side” serifs adorn the top outside portions of the vertical limbs of the letter. This style of serif is called a square or slab serif and it continued in subsequent class pictures, although 1928 and 1929 offered oblique views of the Block M. The frontal view was restored in 1930, the year Cabot was fired by the regents (February 11). The 1931 picture was significant for urology including both Cabot and his former trainee Reed Nesbit, the sudden head of urology. Curiously, Cabot’s picture remained even in the 1932 picture. His firing left the Medical School without a dean until 1935 when Albert Furstenberg was appointed. Block M with serifs continued through 1944, although with minor variations including one oblique reversion in 1935. Two 1943 class pictures feature separate classes, reflecting the intensified medical education during the war effort. The 1945 Block M has short and thin slab serifs.

 

Three.

A 22-year run of Block M’s with serifs ended in 1946 when the shape simplified to a simple, unadorned Block M outline, sans serifs, containing 33 faculty including Nesbit within the logo.

No 1947 picture is present on the wall. A Block M with serifs returns in 1948. The 1949 picture has no Block M insignia, font, or outline whatsoever. Dean Furstenberg is present and the faculty include Nesbit now with some gray hair. A variant Block M with serifs is present in 1950 and 1951, and now the dean’s name is spelled “Furstenburg.” A sans-serif Block M outline reappears in 1952 including Nesbit again. The traditional Block M outline with serifs is restored in 1953, 1954 (the dean is back to Furstenberg), and 1955. The UMMS lists Albert Carl Furstenberg as dean 1935-59, so the variable spelling is odd. Interestingly, from the urology perspective, junior faculty member Bill Baum, is present in 1953 and again in 1954 then with Jack Lapides. Narrow and tall serifs adorn the Block M outline in 1956 with “Furstenburg” again, but the 1957 picture oscillates back to a sans-serif Block M with Furstenberg and faculty again in the M-shape outline. Serifs returned in 1958. Lapides represented the Section of Urology on his own in 1957 and 1958.

The Block M outline vanished in 1959, replaced by a small filled-in Block M logo over the year. This unusual picture shows no faculty except for President Hatcher and Dean Furstenberg among the medical students. The 1960 picture has a sans-serif Block M symbol, but as in the previous year no pictures within the logo. Nesbit returned that year among 26 faculty shown with the class, plus the university president, Dean Furstenberg, emeritus dean, 2 assistant deans, and one administrator. A solid filled-in black Block M logo is present in 1961, but the picture contains no faculty. Redundantly, that year, the class officer pictures show those students a second time. The same format repeats in 1962. Faculty return to the picture in 1963 but only 42 (presumably only senior ones) plus a non-faculty administrator within a Block M sans-serif, that repeats in 1964 with faulty including Nesbit. That pattern persists in 1965 with 27 faculty including 2 “class mentors” and some chairs. Also present are President Hatcher, the hospital administrator, and an assistant administrator. Nesbit is missing again.

Since 1966 each picture features a fairly typical Block M outline with slab serifs and faculty embedded the letter. Nesbit was back in ’66 but looks older and returns in 1967 for his last picture, gone finally in 1968, the year of his retirement. Lapides appears as section head of urology in 1969, but isn’t pictured again. The picture format has remained relatively stable since then, although as faculty grew to over 2500 by now, general faculty pictures were replaced by dean’s office faculty and chairs.

With the recent expansion of Michigan Medicine’s footprint and regional affiliations the Block M has undergone tweaking and constraints, reportedly to maximize its effect. Articles in the Michigan Daily by Austen Hufford (October 20, 2014) and Tim Cohn (March 28, 2017) explain the evolution of the maize-colored Block M from an 1888 football team photo and 1891 team uniforms to its present proxy for the larger University of Michigan. Michigan’s branding blossomed under athletic director Don Canham, as reported by the late great sports writer Frank Deford in Sports Illustrated in 1975. [Deford. No death for a salesman. Sports Illustrated. July 28, 1975]

[Above: instructions on use of the University of Michigan logo]

 

Four.

West Shore Urology. The Block M will extend to Muskegon and the West Shore Urology (WSU) practice this fall. Started in 1972 by Thomas Stone (retired in 2000) the practice now consists of Kevin Stone (son of Thomas), Joe Salisz, Jennifer Phelps, Brian Stork, and Adam Walker (in Alaska at the time of picture) who join us as Clinical Assistant Professors of Urology as their practice becomes a UM ambulatory care unit. WSU is a high-level practice with philosophical commonalities to UM and strong ties, particularly through the Michigan Urological Surgical Improvement Collaborative (MUSIC) run by David Miller and now Khurshid Ghani. We will learn how to collaborate at a significant distance. Lisa Thurman is the PA at WSU.

Joe, Brian, and Kevin trained at Beaumont, and Jessica at Henry Ford, institutions populated by Nesbit alumni including Ananias Diokno, Jay Hollander, Evan Kass, and Hans Stricker. Adam Walker trained with Nesbit alumnus Barry Kogan at Albany Medical Center. Adam, a Hillsdale College and University of Minnesota Medical School graduate, comes from Elmendorf-Richardson Joint Base in Alaska where he was Chief of Urology, a position formerly held by our Nesbit alumnus David Bomalaski. Dave, by the way, remains in practice in Anchorage as the only pediatric urologist in the state and in the entire Indian Health Services system. The WSU team staffs Hackley Hospital, Mercy General Health Partners, Gerber Hospital in Fremont, North Ottawa Community Hospital, and Muskegon Surgical Center. Their diverse skills and perspectives will enlarge our Department.

 

Five.

American artist Jacob Lawrence (1917-2000) was born 100 years ago (September 7). I first saw his work at the Phillips Collection in Washington, DC when in town for a meeting of the American Academy of Pediatrics Section on Urology. His 60-panel Migration Series, funded by the Works Progress Administration and completed in 1941, illustrated the story of the Great African-American Migration from the rural south to the urban north, beginning around 1910. Lawrence worked on the paintings more or less simultaneously to maintain a uniform stylistic sense, he called “dynamic cubism” and considered the work a unity rather than 60 individual paintings.

Fortune Magazine in 1941 published 26 paintings from the series. Ironically, the paintings are now divided between the Phillips Collection (odd-numbered), where I first saw Lawrence’s work, and the Museum of Modern Art in New York (even-numbered). In 2015 and 2016 the split collections were merged and exhibited as a complete set at each museum before returning to their previous homes. Three-dimensional reconstructions of this work form the introduction to the current Kathryn Bigelow film, Detroit. Lawrence told other stories in collections of paintings featuring Harriet Tubman, Frederick Douglass, John Brown, Toussaint L’Ouverture, and a set called The Builders Series.

[Photograph above: Jacob Lawrence, Peter A. Juley & Son Collection, Smithsonian American Art Museum J0001840. Original photograph by Geoffery Clements. Image courtesy of the American Federation of Arts records, 1895-1993 in the Archives of American Art, Smithsonian Institution. Below: John Brown as surveyor in The John Brown Series. © The Jacob and Gwendolyn Knight Lawrence Foundation]

 

Six.

Throughout most of human history health care was delivered by single individuals. Presumably starting out in clans and villages our predecessors in healthcare accumulated healing skills through practice of their arts. Midwives, shamen, herbalists, and the stone doctors mentioned by Hippocrates, specialized in skills. By mid-16th century specialists such as internists, barber-surgeons, and apothecaries were assembling in guilds. Subspecialization reached full display in mid-20th century, when most physicians sought special knowledge and skills based on organ systems, technologies, age groups, or sites of service such as emergency departments and ICUs. The career-defining piece of medical education shifted from medical schools to graduate medical education (residency training) now involving over 100 areas of focused practice, often taking as much time or more than medical school years. The downside of this plethora of specialties is a complex clinical terrain in which patients shuffle among specialists, responsibility is diffuse, hand-offs incur errors, patient satisfaction sinks, and costs soar.

It is natural that arborization of medical skills is countered by nostalgia for omnipotent physicians to take complete care of patients or at least “quarterback” the specialists. This notion of primary care vs. specialty care, however, is more a political distinction than an epistemological one. The idea that everyone should have a “primary” caregiver who will identify specific needs for “specialty care” in patients and make proper referrals (administratively approved by third parties) is attractive, but the reality is that many, if not most, patients needing something specific, identify that need themselves – broken bones, eye trouble, urinary infection, chest pain, etc. – and find care through an emergency department or direct referral to specialists. The modern dilemma of coordinating health care teams, epistemologies, funding mechanisms, education, research, public policies, markets, while maintaining equity is acute. This is the arena of health services research.

Our Dow Health Services Research Symposium is in a bye year, and will hold its 4th meeting in 2018, highlighting our best faculty and resident work and bringing notable young urologists from across the country to similarly showcase their academic wares. Above you see last year’s symposium where Chad Ellimoottil, Michigan Urology Assistant Professor, highlighted Avedis Donabedian, Michigan’s great founder of health services. I first heard Donabedian’s name through Jim Montie and David Miller who gave me the classic 1966 paper. [see Berwick and Fox, Milbank Quarterly 94: 237, 2016] Health service researchers frame clinical problems one way, urologists view them another way, patients have personal points of view, and family members have their own perspectives. All those visions matter, although that of the patient usually dominates for it is on the patient’s behalf that society marshals the resources of treatment.

 

Seven.

Responding to thoughts on secularism and sectarianism in these pages last month, my friend David Featherman – Professor Emeritus of Sociology, Psychology, and Population Studies and former Director of Michigan’s Institute for Social Research – took my comments to a deeper and more significant level, writing:

“Of course, the most common antonym of secular is sacred, although partisan or sectarian appear in some thesaurus sources, as you note. As a general mental puzzle for me these days I wonder if our secular society, for all its other benefits you note, has verged, in some instances or quarters into sectarianism – in the sense of illiberal, intolerant and perhaps even partisan … Certainly, what I point to is not religious sectarianism, although one might admit to a quasi-religious sectarianism …
Those docs-to-be [referring to the White Coat Ceremony], touching patients with their stethoscopes, strike me as potentially moving beyond the non-spiritual or secular into a realm of human interaction not entirely bound by rationality and reason or lacking in the stuff of human compassion or failing to acknowledge something like a ‘mystery’ in life and death … What strikes me as I write is that the white coat might symbolize one of the larger dilemmas of our time, namely, how to draw upon the sacred and the secular as complementary resources …
If zealots … only can see opposition, in archly incommensurate terms, we shall fail to build that cosmopolitan, tolerant but at the same time spiritually, morally, and ethically grounded world. Without the latter resources, an exclusively secular world of wholly liberated individuals can easily lose its bearings to entropy. Those young docs in training have extraordinary opportunity to teach us how to achieve a more complementary cosmopolitanism, day by day, patient by patient.”

David’s point, in a nutshell, seems to be that we cannot isolate secular professionalism of health care from a notion of the sacredness of human life and morality. This veneration transcends specific religions, deities, or other schools of belief, but it is a sacredness that the secular world needs to contain, even if this seems somewhat paradoxical. Lacking this, Professor Featherman rightly professes, a secular society and its cosmopolitan world of nations, religions, markets, universities, politics, and corporations, spin out centrifugally and dissolve into entropy.

 

Eight.

The eclipse last month brought a moment of cosmic uncertainty to the uninformed, although astronomers profess that the occurrence was totally predictable and certain, occurring completely over the continental United States. [Above picture from Hinode Solar Observatory Satellite JAXA/NASA. August 21, 2017.] My colleague Philip Ransley, who has split his career between pediatric urology and chasing the moon’s shadow, gave a lovely talk on lunar eclipses when he received the Pediatric Urology Medal from the American Academy of Pediatrics in 2002:

“There is a beautiful rhythm in moonrise and rhythm in sunset. But there is nothing to compare with standing high on the Bolivian Altiplano in the center of the cone of the moon’s shadow with sunset all around and the eclipsed sun hanging in the darkness. Here, the majestic progression of time is played out before your eyes. An eclipse is quite an extraordinary coincidence. The sun is 400 times larger than the moon. By coincidence it is exactly 400 times farther away, and so the moon just covers the sun. But beware! We live in special times. The moon is moving away from us by a few centimeters each year. That is more than a meter further away than it was when I started coming to AAP meetings, and after only 2,000 million more annual meetings the moon will have moved so far away it can no longer cover the sun.” [Ransley. Chasing the moon’s shadow. J. Urol 168:1671, 2002]

This geometric coincidence is a cosmic rarity of time and space. Science writer George Musser wrote: “In all the hundreds of billions of our Milky Way galaxy, few, if any, are likely to produce total eclipses like ours.” [NYT Aug 6, 2017. The great American eclipse of 2017.] Rare moments of eclipses once terrified our ancestors, jeopardizing their routine predictability of day and night. Mark Twain’s 1889 book, A Connecticut Yankee in King Arthur’s Court, tells of an engineer who, after a head injury, finds himself in 6th century England and convinces people he is a magician by using the tricks of modern knowledge, such as predicting the eclipse of 528. Edmund Halley in 1691 applied the name Saros, from an 11th century Byzantine lexicon, to the eclipse cycle of 6585.3211 days that predicts when nearly identical eclipses occur. Halley’s appropriation of the name may be technically inaccurate with respect to the number, but it has endured. The celestial dance of Sun and Moon, from our point of view as Earthly audience, produces spectacular moments of eclipse when the two bodies seem to become one. Knowledge transforms those coincidences from terrifying episodes of uncertainty to predictable occasions of beauty. [Above: lunar eclipse diagram, Tom Ruen. Wikimedia, public domain.]

 

Nine.

A transatlantic collaboration between Ann Arbor and Copenhagen, initiated 23 years ago by Dana Ohl and Jens Sønksen (above) culminated 2 years ago in Denmark with a conference branded as CopMich, and reconvened here in Michigan for 3 days last month with 50 excellent talks from junior and senior faculty of both institutions, plus our residents and fellows (below). Dana and Jens plan to continue this on a 2-year cycle, offset with our biennial Dow Health Services Research meeting. Our Andrology Division under Dana Ohl has grown to 4 clinicians including Jim Dupree, Miriam Hadj-Moussa, and Susanne Quallich Ph.D. (nursing). Jens spent a year working with Dana in 1994 and has maintained close ties with Michigan Urology. Our new residents room is named for Jens.

CopMich has expanded beyond andrology to include stone disease, voiding dysfunction, pelvic pain, and robotic oncology surgery with speakers from our department and the Department of Urology at Herlev and Gentofte Hospital and the University of Copenhagen, where Jens is Professor and Chair. Guest speakers were Manoj Monga, Director of the Stevan Streem Center for Endourology and Stone Disease at the Cleveland Clinic as well as the American Urological Association Secretary, and Chris Chapple of the Royal Hallamshire Hospital in Sheffield UK and Secretary General of the European Association of Urology. [Below: Manoj and Chris]

Michigan’s own celebrities spoke at CopMich program as well. Ed McGuire, emeritus professor and chief of urology (1983-92) and John DeLancey Professor of OBGYN have virtually defined the intellectual and clinical terrain of female pelvic medicine and pelvic floor neuroanatomy. Dee Fenner, like John, is also a joint faculty member of Urology and esteemed throughout the world. [Below: McGuire, Fenner, DeLancey]

The meeting, offering 15.75 CME credits, was underwritten by both academic units as well as ReproUnion and the Coloplast Corporation. Stig Jørgensen (below) represented ReproUnion and gave an excellent presentation on its funding mechanisms in Europe.

The Danish contingent was superb (partial contingent below) and, after all, there is nothing like a Dane (apologies to Rogers, Hammerstein, and South Pacific).

 

Ten.

My daughter Emily is an Irish literature scholar, so any mention of WB Yeats is likely to catch my attention, especially in an administrative meeting. This happened recently when Marschall Runge brought Dr. Fionnuala Walsh, former senior vice president of global quality at Lilly, to his regular meeting with the department chairs to describe the company’s quality journey to operational excellence. Her presentation perked me up with a reference to Yeats, specifically the last 2 lines in his 1928 poem Among School Children:

“O body swayed to music, O brightening glance,
How can we know the dancer from the dance?”

Novices like me can hardly guess exactly what Yeats had in mind with this thought, beyond the obvious conflation of performer and performance, but that’s the beauty of art in that one’s personal experience as the viewer or reader is where meaning is ultimately ascertained. Yeats also reflected on dance in other works, notably Sweet Dancer, a poem begging the audience to let the dancer “finish her dance.” [EC Bloom. W.B. Yeats’s Radiogenic Poetry in The Wireless Past. Oxford University Press. 2016] Sweet Dancer was first published as a radio play in 1937, a time described as Yeats’ “second puberty.” Yeats’s life, like most, intersected with urology and for him the coincidence most famously was his Steinach operation in 1934. [MA Kozminski, DAB. J Urol. 187:1130, 2012]

That metaphor of unity between art and artist surfaced again recently in a JAMA article by Kimberly Myers called The Paradox of Mindfulness: Seamus Heaney’s “St Kevin and the Blackbird.” [JAMA. A Piece of My Mind. 318:427, 2017] Myers reflected on the challenging impact of fatigue on a person’s attentiveness to responsibility and compassion and links the allegory of the medieval monk to the modern health care provider.
“One might say of the physician what St Anthony says of the monk: ‘The prayer of the monk is not perfect until he no longer recognizes himself or the fact that he is praying.’ … commitment to patient-centered medicine is noble, and it is arduous. And, as is true with any other clinical skill, perhaps it is only with years of practice and continual commitment to being one’s most authentic self in the work he is called to do that it becomes second nature, part of his very body, blood, and bones. Perhaps we are indeed most mindful when we are least aware of being mindful – to borrow a beautiful phrase from another Irish Nobel laureate, W.B. Yeats, when we no longer ‘know the dancer from the dance.’”

This idea brings me back to last month’s reflection on performance and the aspiration of going beyond mere competence to achieve excellence in one’s work. As medical faculty perform the work and study of health care while educating their successors, the moments of our performances are quantum bits of education for those who learn from us. Our best clinical and academic performances can inspire a future physician for a lifetime.

When we fall short we hope our observers have compassion for our human frailty, but that they are challenged to surpass us in their work. The extraordinary emergence, when a dancer achieves unity with a dance, is the very art of medicine that glues us together and inspires those who follow, now in the third century of the University of Michigan.

 

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

Matula Thoughts July 7, 2017

DAB What’s New July 7, 2017

 

The Fourth, stories, & art

3789 words

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

Flag

One.              

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

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

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

Fireworks2

[Fireworks, Barton Hills 2017]

 

Two.

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

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

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

 

Three.

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

Ian & Ted

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

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

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

 

Four. 

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

Point counterpoint

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

 

Five.

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

Fire_ants_01

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

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

 

Six.

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

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

400px-RoswellDailyRecordJuly8,1947

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

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

 

Seven.          

Lapides copy 3

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

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

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

 

Eight.

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

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

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

Bronze star

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

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

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

 

Nine.

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

 

Ten.

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

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

Gibbes

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

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

AAAF 2016

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

 

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts June 2, 2017.

Qualification, adaptations, & stories

3876 words

 

 

One.  

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

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

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


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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

 

Five.

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

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

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

 

Six.    

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

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

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

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

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

 

Seven.

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

 

Postscript

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

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

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

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

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

April facts

DAB Matula Thoughts April 7, 2017

 

April facts – mischievous & urological

3687 words

 

One.              

            April, the first 30-day month of the year, opens up the northern hemisphere spring with welcome visibility of diverse flora and fauna. It should surprise no one that the diversity of life sustains all life on the planet and loss of that diversity imperils everything. A multitude of critters share our space and today it is the wombat that comes to my mind. Australian newspapers The Sydney Herald and The Age reported a wombat attack this day in 2010 when a man named Bruce Kringle ended up in the hospital after mauling by the marsupial. The worldwide British Broadcasting Corporation quickly picked up the news. These sizable animals average over 3 feet and 60 pounds as adults. [Photo by JJ Johnson. 29 November 2009. Taken at Maria Island National Park, Tasmania.] Territorial infringement was likely in play in this instance, as the victim was living in a camper when he stepped out the door and encountered the angry wombat, unusual behavior for the animal and ultimately self-destructive after Kringle found an ax and made short work of it on this summertime February day in Australia.

The Wombat coincidence this day on this April day piqued my interest, because in a previous April, 1998, the British Journal of Urology (BJU) published an article on wombat uroflowmetry. [D. Johnson. Case report. Observations on the uninhibited bladder of the common wombat. BJUI. 81:641-642, 1998.] For those readers uninitiated regarding matters of scientific micturition, uroflowmetry is the measurement of the flow rate of urine during the process of emptying the bladder. Mankind is naturally curious about its personal byproducts and inspection of sputum, urine, feces, etc. has offered clues to understanding disease since the times of the earliest healers. Of course most mammals have olfactory interest in their own urine and that of others, as evidenced in the canine world. Uroflowmetry provides true facts about urination, thanks to our ability to measure time and volume, as well as understand velocity.

My interest in uroflowmetry preceded the wombat stories and goes back to Walter Reed Army Medical Center where my chief, Ray Stutzman, introduced me to the concept of timed uroflowmetry and we wrote a paper comparing it to instrumental uroflowmetry. [J. Urol. 133:421, 1985] I then wondered about uroflowmetry in other species and the elephant seemed a good place to start. Discussion with the elephant-keeper at the Washington National Zoo taught me something about pachyderm urologic habits, but we never completed the project, mainly because of a difference of opinion on the distribution of the tasks required by the methodology. Timed uroflowmetry requires a collection device and a stopwatch to measure the volume during 5 seconds of mid-flow. All of the elephants at the Washington Zoo at the time were female and their streams therefore required a collection device both large in volume and wide in aperture– basically a big bucket. The unpredictability of elephant micturition required someone standing in place with the bucket. Since the uroflowmetry idea was mine and the elephant-keeper was on better terms with the pachyderm than I was, it seemed reasonable for me to hold the watch while the other guy held the bucket. The elephant-keeper disagreed with that assignment and claimed the stopwatch. Given that stalemate, the study has yet to be performed and awaits an ambitious medical student or resident, or a more flexible elephant trainer.

Another elephant crossed my path around this time of year after Ed McGuire brought me to Michigan. A child with gross hematuria presented to clinic with her grandparents and we diagnosed urologic malignancy. After surgery she remained in hospital for further treatment and by this point the parents had come to town. They were circus people and owned a number of animals including a young female elephant. Domino’s Farms graciously allowed the family to camp out on their property for the weeks of therapy, and one spring afternoon the child’s family invited our pediatric urology team and kids for elephant rides.

 

Two.            

            Planarial detour. Scientists crave facts and know their job is to ferret out true facts. Bill McRoberts, colleague in Kentucky, friend, and our third Duckett Lecturer at Michigan used to tell his residents “a little fact trumps a lot of myth,” an idea parallel to Coffey’s advice to trainees:  “you have to understand the difference between facts and true facts.” Evidence, analysis, and experiment are the ways we come to verifiable truths and enduring realities that constitute true facts. While all biological creatures deal with facts of their environment, many facts are only transient realities. A planarium, for example, may sense that its world is 20°C and that food is available straight ahead of its momentary motion, but those facts may change quickly. We humans can examine myths, discover momentary facts, create hypotheses, and perform experiments in search of something we call the truth, an aspiration we think is unique to our species.

Planaria, by the way, are among the simplest animals to manage their waste with a dedicated excretory system.  Paired flame and tube cells ending in a pore assemble as protonephridial tubules along the length of the flatworm. These are capable of regeneration. [JC Rink, HT-K Vu, AS Alvarado. The maintenance and regeneration of the planarian excretory system are regulated by EGFR signaling. Development. 138:3769, 2011] Planarial flow rates could be a topic for a future study. More practically, the mechanism of planarian excretory regeneration could be turned to human renal replacement therapy, thus proving the point that today’s obscure fact may be tomorrow’s revolutionary insight.

[Above: planarian Dugesia subtentaculata. From Santa Fe, Montseny, Catalonia. Wikimedia Commons. Eduard Solà.]

[Above and below: reproductive and excretory systems of flatworm. Source – Wikimedia Commons, Putaringonit.]

            When the wombat uroflowmetry paper in the BJU caught my attention in 1998, I suspected a prank, something not unknown in British medical publications, particularly around the month of April. Thinking a clever reply might be appreciated by the journal, I resorted to limerick form in a letter to the editor, Jeff Chisholm. Surprisingly, my letter was published and now constitutes the only “poetry” of any sort to find its way into my CV. [DA Bloom. Re: Wombat uroflowmetry. BJU 83:365, 1999.] Chisholm annotated my reply: “Edited versions – apologies to the author!” The annotation was in this limerick:

“Lo, the wombat – it all must be true

So free when it’s not in the zoo

Pees lots when it poops

By well-used neural loops

As told in the new BJU”

 

Three.

          Pranks, myths, and propaganda veer from the true facts attended to so carefully in our professions. Last spring, sitting in on the class my daughter Emily, assistant professor in English, was teaching at Columbia University I heard her challenge a familiar myth with data from a paper in Science. [Mehl. Science. 317 (5834): 82, 2007.] The myth was that women spoke more than men, and observation of my children and grandchildren still supports that idea. The thing about myths, however, is that they usually short-circuit our best efforts to think critically. Appealing to the lazy tendencies of our brains, they get an easy pass for “truth.” Although I subscribe to Science, I had missed that particular article (and likely hundreds of other important ones since then). Matthias Mehl, associate professor of psychology and author of the paper, studied 210 women and 186 men with a voice-activated device that captured 30 seconds of conversation every 12.5 minutes (5% of the day) and found that women used 16,215 words and men 15,669 words daily – no significant difference. One might argue that possibly women used longer words for more complex conversations, and inspire another study. Another question, also heavily dependent on educational, socio-economic, and occupational levels of  subjects tested would be how many words does “an average person” hear every day? It is likely that fewer words are actually comprehended than spoken.

Word count interests me in relation to this monthly column, What’s New/Matula Thoughts. Approaching 4000 words it offers a substantial amount to read, a quarter of what most people speak every day. It is surely vain on my part to think that the general readership consumes all these words critically, although a few friends read this more carefully than I write it. My point in writing, however, is that it fills some fundamental personal need to communicate beyond the simple necessities of survival and daily work, the need that our distant ancestors (Homo sapiens, Neanderthals, and their hybrids) fulfilled some 30,000 years ago on the walls of their cave dwellings. These particular electronic postings you now read are hardly so novel, artistic, or durable.

 

Four.             

            More on words. Considering a career in urology a medical student at Pritzker Medical School in Chicago, Logan Galansky, recently contacted me for advice and as she explained her previous work in hearing and learning she described the 30 million words idea – the hypothesis that children who heard that many words by age 3 years had a lifetime advantage over those who were exposed to much less. [B Hart & T Risley. (2003). The early catastrophe: The 30 million word gap by age 3. American Educator, 27(1): 4 – 9.] Complicating any easy assumptions, however, is the fact that the study compared children from “professional families” to children from “impoverished families” in Kansas City, KS in the 1960’s where other confounders beyond experiential words were at play. The pivotal study involved  42 families that were divided into 4 socioeconomic groups. Although scrutiny detracts from the easy conclusion it certainly is plausible, if not likely, that richer vocabulary experiences build more robust vocabulary inventories, and those inventories are an advantage in life.

Our Department of Urology Faculty Retreat next week is a sort of spring training for the next decade of urology at the University of Michigan. Each clinical division and key domain, such as education or the Dow Health Research Division, will present strategic visions. Individual faculty have updated their web profiles and we should get a pretty good sense of ourselves as an organization today and what we hope for in the intermediate future. How many words will be spoken at this retreat? Given pauses, breaks, and other interruptions, and assuming a leisurely rate of 100 words per minute (130-150 wpm may be more typical of conversational speech) over 5 hours we may hear 30,000 words. Who knows what will stick or what people will take away, but I hope we will align around our mission and that we will understand our divisional strategies and visions of the future.

 

Five.              

            Disparities. Important lessons from Star Wars, observed by The Economist and mentioned here last month, bear repetition. First, economic disparities are inevitable in the galaxy, in spite of advancing technology. Second, although free trade advances economic growth, free trade will never benefit everyone equally; some “humans will still labor at dangerous and unpleasant tasks” because of inequities within political systems.

Society benefits substantially by mitigating disparities that, while inevitable in humanity, impede the common good. Society gains when its entire human capital is educated, productive, healthy, and kind. If only certain privileged subsets of its potential workforce have opportunity for education, employment, and productivity, then the potential of that society is diminished. A generation ago, scientific investigation of healthcare disparities was not high on the ladder of interest in academia, federal funding, or industry. This has changed greatly, and our Urology Department Dow Health Services Research Division reflects the new attention. An important paper in JAMA earlier this year looked at trends and patterns of disparities in cancer mortality by counties in the USA from 1980-2014 and the results relevant to urology are riveting. [AH Mokdad et al, corresponding author CJL Murray JAMA. 317:388-406; 2017.]

Prostate cancer:

Kidney cancer:

Testicular cancer:

The United States is a large and diverse country, but why people with specific diseases should have different regional disease frequencies, expectations of care, and survival is a complex question with many answers. Regional variations of disease frequency and survival can depend upon environmental factors such as air or water safety, occupational hazards, poverty, food safety, public safety, weather conditions, and many other factors that vary according to geography and socio-economic conditions. Looking at the maps we have to agree with Dorothy, in The Wizard of Oz, that the center of the country is a good place to call home.

 

Six.

           Centrism. A cornerstone aspiration of American representational democracy is justice, opportunity, and dignity for all participants. This must be balanced against the centrist tendency inherent in majority rule of the electorate. Cosmopolitanism must be respected and those who are disadvantaged require a humane safety net. Life, liberty, and the pursuit of happiness are those basic Jeffersonian beliefs articulated in the Declaration of Independence, but even after more than 200 years they remain work-in-progress, complicated by a world that is rapidly changing in terms of socio-economic, geo-political, environmental, demographic, and technology factors.

The political center of the United States will always be a matter of debate, however the geographic center of the contiguous United States according to the US National Geodetic Survey is 39°50′N 98°35′W. This spot happens to be in Kansas, approximately 12 miles south of the mid KansasNebraska border and 2.6 miles northwest of the center of the city of Lebanon.  Not too far south and east of that point is Abilene, Kansas where Dwight David Eisenhower was raised.

Health care is unquestionably wrapped up in the idea of life, liberty, and the pursuit of happiness, and healthcare politics concerned most presidents even before the mid-20th century. Around that point in time the AMA position was that the federal government should not be involved in healthcare, while Truman favored national health insurance and Eisenhower sought legislation to support the healthcare insurance industry.

On April 16, 1953, twelve weeks into his presidency Eisenhower delivered one of his greatest speeches. This was just a month and a half after the death of Stalin and, as the president then knew, the first hydrogen bomb would be tested within a year (code-named Castle Bravo it was detonated March 1, 1954 at Bikini Atoll, Marshall Islands). Eisenhower saw an opportunity to reset the increasingly costly escalation of the cold war. The occasion was a meeting of the American Society of Newspaper Editors in Washington, DC. Eisenhower worried about the disparity between military spending and the spending of a nation on the life, liberty, and pursuit of happiness of its people.

“In this spring of 1953 the free world weighs one question above all others: the chances for a just peace for all peoples… “

No one dared remind Eisenhower that liberty required a robust and costly position of defense, but he was convinced that the escalating costs were not only excessive, but also realistically unnecessary. He believed that the nations of the world had reached a point where the worst that could be expected by the escalation was terminal nuclear war while the best hope was

“… a life of perpetual fear and tension; a burden of arms draining the wealth and labor of all peoples; a wasting of strength that defies the American system or the Soviet system or any system to achieve true abundance and happiness for all the peoples of this earth. Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed those who are cold and not clothed. The world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children.”

He noted that the cost of one heavy bomber equated to modern brick schools in more than 30 cities, a single destroyer equalled a new home for 8,000 people, or a fighter plane cost a half million bushels of wheat. Inflation and technology have pushed the costs much higher.

 

Seven.

            The Nesbit Society and the AUA come to mind as spring approaches. The AUA originated in 1902 in New York City when urologist Ramon Guiteras felt the need to congregate with other urologists. Barely 17 years later his colleague Hugh Cabot in Boston, returning from WWI, began preparations to move to Ann Arbor attracted by the opportunity to organize a medical school and hospital system to suit the changing times of health care. Cabot’s successor, Reed Nesbit, became the first head of urology at Michigan, presiding for nearly 40 years, followed by Jack Lapides. The Nesbit Society was formed in 1972 under the leadership of the Nesbit/Lapides trainee John Konnak, who by then had become a faculty member. The legacy of these great teachers and urologists is the Nesbit Society, now with 324 members. To a large extent, it is the Nesbit Society to whom this monthly electronic posting is directed (although a few members prefer a hard copy and Sandra Heskett graciously obliges). It is always a delight for me to hear from our Nesbit alumni and friends. John Hall (Nesbit 1970), for example, sent me this phrase that has informed his practice throughout his excellent career in Traverse City:  “We don’t practice medicine until we get it right, we keep on practicing until we will never get it wrong.” Hall’s Theory of Medical Education, like the Hippocratic aphorisms, distills wisdom into a phrase that you can carry around and re-inspire yourself when the going gets rough on a given day in clinic or operating room. This is one of the ways good professionals inoculate themselves against burn-out.

The Nesbit Society meets twice a year: once during the AUA national meeting in Boston this year on Sunday May 14 and all Nesbit members and friends of the department are welcome. The second occasion is our alumni weekend here in Ann Arbor September 14-16.

 

 

Eight.                        

           Most species congregate and the chairs of our academic departments do this with some regularity. I came across this picture of such a congregation 3 years ago in April when Mike Johns was interim EVPMA. This particular dinner was at The Earl, and the picture was taken before everyone had arrived, but it turned out to be my best picture of the evening. [From left: Karin Muraszko, Valerie Opipari, John Voorhees, Mike Johns, Carol Bradford, Reed Dunnick.]

The clinical departments are where the rubber meets the road in carrying out the missions of our UM Health System mission. Departments have been the building blocks of universities for hundreds of years, and academic medicine departments have effectively educated their successors, expanded the conceptual basis of their fields, and performed the essential transactions of clinical care over the past century. The clinical mission is the milieu for education and research as well as the financial engine for academic medicine. The changing economic, regulatory, and technological environments threaten the delicate balance of that mission. At Michigan our ambulatory care unit (ACU) model of delivering care has been successful, with the healthcare providers in central roles of making local operational general strategic decisions more effectively than management by managerial accounting methodology. This is largely the concept of lean process management. Clinical departments bring a third dimension of the academic mission to ambulatory clinics of providers and patients.

 

Nine.

          April, the cruelest month in the view of TS Eliot, can be mischievous and its first day, April Fool’s, sets the tone. The origin of April Fools Day, may well have to do with April being the first calendar month of the year in medieval European towns when March 25 marked New Year’s Day. April in Ann Arbor often brings mischief since a given day may be spring-like while the next might be wintry. That shouldn’t be surprising, as nature routinely throws curve balls to test our fitness. Actually, yesterday afternoon I saw snow flurries from my office window and more snow last blustery evening.

[Above: April 2, 2016 at home. Below: April 13, 2016 Old Mott on left, Main Hospital center, and Taubman on left.]

 

 

Ten.

              Biology’s astonishing diversity sustains our particular human biologic niche, yet ironically our very presence as a species chips away at biologic diversity and erodes our niche. This erosion has been going on for a long time and the angry wombat is only one tiny example. Its likely ancestor, the Diprotodon (meaning two forward teeth), was the largest known marsupial and a member of the Australian megafauna that existed from 1.6 million years ago until extinction around 46,000 years ago. That latter date coincides with the time our human ancestors were making their first cave dwelling paintings as they were eating the megafauna. Koalas and wombats are, perhaps, miniaturized surviving versions of the rhinoceros-sized Diprotodon. The wombat’s dental plan facilitates its Darwinian niche, allowing it to tunnel forward vigorously. Cleverly, its marsupial pouch opens retrograde, to avoid collecting dirt as it burrows. After 3-week gestations, the young live in the pouches for 6-7 months, but still do not wean until 15 months of age. Wombats have no tails and their tough rear hide is cartilaginous most posteriorly, making it resistant to predators. Wombat scat (below) is oddly a nearly perfect cubic form, somehow resulting from its peculiar physiology. Wombat groups are variously called wisdoms, mobs, or colonies. [Wikipedia facts, Photo JJ Harrison]

As the environment changes, you never quite know what to expect each day going forward. One value of knowing some history is that it gives you a little confidence of what to expect. For example, if you know the earthquake history of your location has a frequency of once in a millennium, with the last recorded 100 years ago, you might reasonably conclude that it is safe to live there. More immediately, if the sidewalk you are about to traverse is riddled with pigeon droppings, you might cross the street to walk on more auspicious pavement. When Bruce Kringle woke up 7 years ago in Australia, he certainly had no idea that an angry wombat was going to take him on when he stepped out of his mobile home, although had he examined the ground he might have recognized its unique cubic scat.

[Wikimedia Commons: Bjørn Christian Tørrissen. http://bjornfree.com/galleries.html.]

 

Postscript.   John Barry, in response to the picture of the Olds 88 last month wrote: “Looks like a 1951 Oldsmobile 88 K-body 2 door sedan with a V-8 engine and a Hydramatic transmission. I had one when I was a senior in high school. Great car. I used to buy cars, fix them up and resell them from my parent’s driveway.

Thank you for reading Matula Thoughts this April, 2017.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

March Thoughts

DAB What’s New March 3, 2017

March Thoughts

3741 words

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

 

the_victors_sheet_music

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

or

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

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

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

louis_elbel

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

march

 

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

cave_painting_l

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

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

the-she-wolf

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

 

Three.

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

george_w-_johnson_1898

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

berlinerdisc1897

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

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

jackie_brenston-1

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

 

Four.

1949_oldsmobile_88

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

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

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

 

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

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

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

440px-muenchhausen_herrfurth_7_500x789

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

 

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

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

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

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

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

 

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

sterns-2012

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

 

Eight.

metro

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

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

 

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

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

 

Ten.

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

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

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

————————————————————–

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

734-232-4943

dabloom@umich.edu

 

2017 is here

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

 

grand-rounds

One.

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

galens

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

holiday-party

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

fac-mtg

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

 

 

Two.

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

washington

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

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

Washington set the tone in the opening sentences.

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

The conclusion was optimistic.

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

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

 

 

Three.

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

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

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

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

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

tim-johnson

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

 

 

Four.

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

runge-cantor

 

 

Five.

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

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

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

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

 

 

Six.

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

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

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

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

 

 

Seven.

hamilton

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

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

ham-board

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

mike-clarence

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

ben-team

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

 

 

Eight.

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

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

orson_welles_war_of_the_worlds_1938

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

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

 

 

Nine.

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

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

fifth

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

stats-mid-dec

[Above: MatulaThoughts analytics in mid-December]

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

 

 

Ten.

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

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

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

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

hew-seal

[Above HEW seal; below HHS seal]

hhs-seal

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

 

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