Matula Thoughts August 5, 2016

Posted by dabloom

Matula Thoughts – August 5, 2016

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

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

One.

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

[Dr. Chang & Don Nakayama]

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

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

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

Two.

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

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

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

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

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

Three.

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

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

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

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

[Above: Lapides Lecture, Danto Auditorium]

Four.

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

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

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

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

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

[EO Wilson at UM LSI Convocation 2004]

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

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

Five.

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

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

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

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

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

Tu_Youyou_and_Lou_Zhicen_in_1951.TIF

Six.

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

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

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

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

Seven.

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

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

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

[PG Ransley c. 2005]

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

Eight.

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

[From Atlantic States Marine Fisheries Commission]

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

[Bove: ruthless foragers]

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

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

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

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

Nine.

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

Ten.

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

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

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

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

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

Thank you for reading our Matula Thoughts.

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

Commencement 2016

Posted by dabloom

DAB What’s New –July 1, 2016

3805 words

One.

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

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

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

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

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

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

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

Two.

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

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

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

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

Three.

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

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

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

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

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

Four.

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

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

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

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

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

Five.

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

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

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

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

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

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

Six.

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

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

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

Seven.

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

[Above: Caleb Nelson. Below: Bart Grossman]

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

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

Don Nakayama

Eight.

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

Nine.

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

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

Ten.

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

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

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

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

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

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

Matula Thoughts June 3, 2016

Posted by dabloom

DAB What’s New/Matula Thoughts June 3, 2016

3659 words

Periodic explanation: What’s New is a weekly email communication from the University of Michigan Department of Urology. Most Fridays it is distributed internally to faculty, residents, and staff, dealing with operational specifics, personnel, and programs of the department, but on the first Friday of the month it is general in scope as “a chair’s perspectives” and is distributed more widely to alumni and friends of the department. The website (blog) version is matulathoughts.org.

One. Springtime & Montie. Spring declared itself in Ann Arbor early last month when flowers, shrubs, and trees began to wake up from the winter, while many Michigan urologists headed out to San Diego for the national meeting of the American Urological Association. There Jim Montie received the Lifetime Achievement Award, a distinguished honor for a great career.

[Picture above: NCRC trees waking up near the Keller Laboratory; below: kudos to Jim Montie]

Michigan Urology owes much to Jim who took the helm during a turbulent era of our Section of Urology in the Department of Surgery in 1997. He stabilized our unit without disturbing its essential deliverable of kind and excellent patient-centered care while standing solidly for the other key parts of our academic mission, education, and research. Jim led our Section of Urology to departmental status and became inaugural chair in 2001. As a world-class clinician and surgeon his reputation is unsurpassed. Jim’s foresight in recognizing the potential for health services research in urology and his courage in “betting the farm” on it within our new department led to our key position in academic urology today. This is a good year for Montie awards, as Jim will also be receiving the UM 2016 MICHR Distinguished Clinical and Translational Research Mentor Award.

Above you see Jim in an older picture with his own mentor, Ralph Straffon (Nesbit 1959), another great Michigan Urologist. Ralph, also honored by the AUA during his lifetime, became President of the American College of Surgeons and led the Cleveland Clinic to its excellence.

Two. AUA & Nesbit. The national meeting of the American Urological Association is an annual ritual that mixes science, technology, networking, and reunions to the general advantage of our field of urology and to the public it serves. Our Department of Urology figured prominently at the meeting this year with over 120 presentations by faculty, residents, and fellows. Additional work produced by our Nesbit alumni at large and former students nearly doubled that number. The MUSIC reception on Saturday highlighted productive collaborations of urologists throughout Michigan and regionally that have measurably improved urologic practice. Envisioned by Montie and led in turn by John Wei, Brent Hollenbeck, David Miller, and now Khurshid Ghani, the collaborative is an international model for medical practice improvement, centered where it should be centered – at the professional level. This lean process approach has been generously funded by Blue Cross/Blue Shield of Michigan.

[MUSIC Collaborators: Khurshid Guru of Roswell Park, DAB, Jim Peabody of Henry Ford, Ahmed Aly of Roswell Park]

Our Nesbit Reception on Sunday evening hosted 130 alumni, faculty, residents, and friends of Michigan Urology from Sapporo, Japan to Copenhagen, Denmark. We additionally were pleased to see chairs from other departments of urology in this country including Joel Nelson from Pittsburgh, Mani Menon from Henry Ford Hospital, Marty Sanda from Emory, and Tom Stringer from Gainesville, Florida (former chair). Three father-son urology pairs attended our event – Ian & Robert McLaren, Len (Nesbit 1980) & Jack Zuckerman (currently at Portsmouth Naval Hospital), and Mike and Michael Kozminski (Nesbit 1989, 2016). In spirit we thought of Carl Van Appledorn (Nesbit 1972 who passed away last month) and his son Scott, a urologist in practice in Kirkland, Washington. Another urology family attended the Nesbit reception – Kate Kraft and her uncle Kersten Kraft (a urologist trained at Stanford and in practice in the San Jose area). Kersten coincidentally is a relative of Norm Hodgson (Nesbit 1958), a great pediatric urology pioneer who practiced in Milwaukee. Other UM Michigan urology pairs, not in San Diego this year, include Cheng-Yang and Ted Chang (Nesbit 1967 & 1996), Marc & David Taub (Nesbit 1971 & 2006), the late L. Paul Sonda II & his son Paul Sonda III (Paul II finished urology under Lapides at Wayne County Hospital in 1962, Paul III Nesbit 1978), and of course Reed Nesbit and son-in-law Roy Correa (Nesbit 1965).

[Above: Bob & Ian McLaren, below: Len & Jack Zuckerman]

[Above: Tim Miller (London, UK), Jens Sönksen (Nesbit 1996), Jim Dupree (faculty), Dana Ohl (Nesbit 1987).

Below: Miriam Hadj-Moussa (Nesbit 2016), Quentin Clemens (Nesbit 2000), Lindsey Cox (Nesbit 2015), Irene Makovey (Cleveland Clinic), Yahir Santiago-Lastra (fellow, Nesbit 2016)]

Three. Corrections & kudos. Like me, you are likely deluged by email, electronic feeds, newsletters, and blogs so you necessarily pick and choose what you attend to with the slow thinking part of your brain (to use terminology of Daniel Kahneman – Thinking, Fast and Slow, 2011). I am thankful that this monthly column, What’s New/Matula Thoughts, has found a loyal readership to inspect these words in detail and catch me up for inaccurate claims. My friend John Barry is one of those who keep me on my toes. After my mention of Joe Murray in our March edition (with reference to the history of human renal transplantation and my old teacher Will Goodwin), John referred me to a historical paper in the Journal of Urology he authored with Joe Murray in 2006 [Barry & Murray. The first renal transplants. J. Urol. 176:888, 2006]

Reading this paper I learned that the first human kidney transplantation was performed in 1933 by Yu Yu Voronoy in the Ukraine, although the outcome was not good. Other attempts followed in Boston, Chicago, and Paris, but the first long term success was achieved by Joe Murray along with Hartwell Harrison and their team in Boston in 1954. Total body irradiation improved subsequent results, followed by pharmacological immunosuppression. Goodwin was the first to use glucocorticoids to reverse rejection. The transplantation story is clearly more complicated than I thought.

[Two notable urologists: Parry & Barry]

John Barry (R) is shown above with Bill Parry (L), one of the great statesmen and historians of urology. Bill Parry had a distinguished urologic career in Oklahoma. Many paths in the history of worldwide urology trace back to Michigan and accordingly Bill credits William Valk (Nesbit 1943) for significant mentorship. Valk went on from Michigan to become Chair of Urology at the University of Kansas and served as President of the American Board of Urology. I recall Valk’s name from correspondence at the time I was getting my board certification. Valk spent six years in Ann Arbor amidst the heyday of BPH as the index disease of urology and TURP was its signature procedure. Reed Nesbit and Ann Arbor were the international epicenter of prostate expertise. Things change in medicine and the TURP is giving way to other modalities (including the histotripsy method of Will Roberts and his team). Renal transplantation, once a core part of urology’s domain, remains so only at a few centers today including UCLA and Portland, Oregon where John Barry, former chair, is a rare urologist with a strong presence in that realm.

Four.

[Pythagoras, contemplating his idea: by Peter Fischli & David Weiss, Swiss artists recently exhibited at the Guggenheim]

History. Written history is ultimately a matter of finding clarity from evidence and out of critical analysis of anecdotal stories. New information improves the historical interpretation of events and is an important part of ongoing scholarly investigation that sharpens the rigor and truth of any field. Knowing the past adds meaning to today and gives perspective to the challenges of tomorrow.

Mathematics, for example, is best understood from the perspective of the stories of people, from Pythagoras, to Euclid, to Newton, to Fermat, etc. Whether Newton’s apple was a real event, a thought experiment, or a wild speculation may never be known unless some evidence turns up from a discovered letter, a diary, genetic evidence of an apple orchard at the site of Newton’s garden, or a time machine. The story of urology is also incomplete, but is rapidly evolving from the days of Hippocrates’ admonition against cutting for stone to the latest chapter of robotic prostatectomy. All stories bear re-inspection and who, after all, is better equipped to do the scholarly inspection than those participants with knowledge of each story? Historical inquiry is a fundamental part of the scholarship of all disciplines.

Five. Change is in the air. A recent paper called Injurious Inequalities, by David Rosner of Columbia University, caught my attention with the statement: The close relationship between a nation’s physical health and its economic and political health has been a central tenant of statecraft since the rise of the mercantile economy in the 18^th century. [D. Rosner. Milbank Quarterly 94:47, 2016] On more levels than easily counted, politics and health are closely linked. Today’s public is uneasy and change is in the air. Of course change is what elections are about, but this time the issues and consequences of their resolution seem more substantive. Change was in the air around the time of the Arab Spring, yet humanity doesn’t seem to have benefited from the resulting change. Certainly the sum total of human happiness is no greater since that springtime. Stability may not be relished by the populace, but it seems preferable to unbounded terrorism, genocide, massive waves of immigration, and erosion of national borders.

When I was a youngster, learning to spell, the rumor on the streets of my pre-adolescent peers was that the longest word in the English language was antidisestablishmentarianism. Being a nerd back then, it was somewhat of a rite of passage to know that fact and to be able to spell the word. Probably our language has longer words and, anyway, nerds today define themselves digitally. Antidisestablishmentarians seem to be a rare breed currently, or perhaps disestablishmentarians are barking louder today in political conversation directed at taking down establishments, an ambition that seems rather anti- conservative.

Antidisestablishmentarianism has roots in 19^th century Britain, developing as a political position opposing liberal proposals to disestablish the Church of England as state church for England, Ireland, and Wales. The word now refers to any general opposition to those who would disestablish government, public programs, or other established parts of society.

Six. Germinal ideas. Sometimes disestablishmentarianism is the right thing. Recently these pages discussed Holmes, Semmelweis, and Lister with reference to the germ theory, an essential building block in the modern conceptual basis of health care. Many authorities of the time not only were nonbelievers, but became vehement antisepsis-deniers. Amazingly, incomplete appreciation of the reality of germ theory is still evident in the under-utilization of genuine handwashing, covering coughs, or sneezing into handkerchiefs. The setting for Semmelweis, at the University of Vienna, is an illuminating case study. The late Sherwin Nuland, surgeon and faculty member at Yale and friend to many here at the University of Michigan wrote about this in his introduction to a modern translation of Semmelweis’s book.

“The University of Vienna, most particularly its medical school, was a hotbed of revolutionary activity. The uprisings of 1848 were strongly supported by the younger faculty members, largely because the university was under stifling control of government ministries. Some of the major positions at the school were held by professors who were old in years and who owed their power to close connections with those very same bureaucrats. They became arrayed against the younger faculty whose liberal policies and new ideas in research and pathophysiology they opposed.” [Nuland in Etiology, Concept and Prophylaxis of Childbed Fever by Semmelweis. Classics of Medicine Library. Birmingham, 1981. P. xvi.]

The ideas of Semmelweis, embraced by only a few of his mentors and colleagues, were perceived by the establishment as threatening. Nuland frames this as a conflict between “the flow of true understanding of pathophysiology versus the fuzzy theoretics of nonscientific medicine.” The younger crowd in Vienna embraced the new idea that puerperal fever was transmissible. Semmelweis made the proper and seminal distinction that childbed fever is a transmissible but not a contagious disease.

Semmelweis had been an upstart outsider in the eyes of established senior colleagues who controlled appointments and when his appointment as assistant in obstetrics expired in March of 1849 it was not renewed. Younger colleagues (Rokitansky, Skoda, and Hebra) spoke on for his idea and ultimately coaxed the authorities to allow Semmelweis to speak about his work and urged Semmelweis to give a talk at the Vienna Medical Society. This happened on 15 May 1850, although Semmelweis didn’t submit written remarks. Accordingly the speech, first public record of his idea, was only recorded as an abstract in the minutes of the society. Nonetheless Semmelweis must have been somewhat persuasive and he was offered a minor clinical appointment. This must have offended him, however, and he abandoned Vienna and his supporters abruptly in October of 1850. The Etiology was not published until 1860 and Semmelweis died in 1865.

Seven.

Poppy fields. One free afternoon during a recent meeting in Texas, Martha, Linda Shortliffe, and I visited the LBJ Ranch north of San Antonio and west of Austin. Remembering the LBJ presidency, but hardly a student of the era, I was surprised to realize the shortness of LBJ’s terms, somewhat over 400 days in total, and equally surprised to learn that Johnson spent a quarter of that time at his ranch, requiring a large entourage of support. A poppy field nearby (shown above) caught our “fast-brain attentions” and we pulled over for slow-brain inspection. I recalled two other poppy fields. One, you too might remember, was in The Wizard of Oz by L. Frank Baum. The original text in 1900 portrayed the vapors from the poppy field as enticing fatal sleep – and only narrowly did Dorothy and her companions escape.

In the 1939 film the 5 travelers were lulled into temporary sleep that allowed nasty flying monkeys to carry them off to the Wicked Witch of the West.

The other poppy field I recalled was real in Normandy, France in 2010. Intending to visit the famous beaches and other sites of WWII, we came across a large poppy field on the mainland from which I first viewed Mont Sainte-Michel, floating a short distance offshore. The Normandy poppies although sparser than we would see in Texas 6 years later were equally stunning. [I took the picture, below, with my Blackberry camera phone, which could hold little more than a few dozen pictures].

Field notes: The poppy is a flowering plant in the Papaveraceae family according to the binomial system of Linneaus, who was far better known for his botanic studies than for his short career as a proto-urologist in early 18^th century Stockholm .

[Robert Berks sculpture of Linnaeus, Chicago Botanic Garden. Taken May 23, 2009]

The species, aptly named Papaver somniferous, is the source for well-known medicinal and “recreational” alkaloids, in particular opium and morphine. Poppy seeds, edible and tasty, lack the narcotic factor and are also a source of poppy seed oil. The poppy fields of Flanders became terrible places of trench warfare during WWI and perhaps for that reason poppies, like rosemary, are a symbol of remembrance around Memorial Day.

Eight. Memorial Day & sad transitions.

Earlier this week (May 30) we paused at Memorial Day. You may recall that Memorial Day was first celebrated in 1868 as Decoration Day in memory of soldiers who died in the Civil War, although it was only celebrated in the north until 1890. After WWI the holiday honored the memory of all Americans who died in wars, and in a cosmopolitan sense it also reminds me of anyone who dies in service to their fellow man or those who die from the disservice of their fellows. Memorial Day reminds me, too, of the waste of war, some wars being sadly virtuous while others are failures of diplomacy and excesses of greed, tribalism, and stupidity.

The federal holiday was traditionally celebrated on May 30, whatever day of the week that happened to be. In 1968 the Uniform Holidays Bill created 3-day holiday weekends, with the last Monday of May assigned to Memorial Day.

Most acutely, Memorial Day reminds me of friends gone by such as Carl Van Appledorn (Nesbit 1972) last month, and last year Gordon McLorie, Tom Shumaker, Bill Steers, and Adrian Wheat, a career Army surgeon and expert on Civil War medicine.

[Above: Joe Cerny, Carl, Cheng-Yang Chang. Below Gordon, Tom & Sharon Shumaker, Bill Steers, Adrian Wheat]

Nine. Good transitions. This year 4 anchors of the Urology Department are moving on to great new phases of their careers.

Gary Faerber is in Salt Lake City with a terrific urology team at the University of Utah where his wife Kathy Cooney is the new chair of internal medicine at the University of Utah. Gary will be returning to us for quarterly clinics at our Hamilton FQHC in Flint.

Cheryl Lee will become chair of urology at Ohio State, an opportunity not only for a new challenge, but also a chance to get her family in the same city as her husband’s twin and his family. She will be a loss not only for us in the Urology Department, but also for our Dean’s Office where she has been managing the Office of Career Development for the Medical School.

Our irreplaceable Ann Oldendorf is retiring. No one can sort out a complex UTI or deal with complex neurourological dysfunction such as seen with interstitial cystitis with more expertise, patience, and kindness than Ann. Our PA Gayle Adams will be picking up some of that work, but Ann was a unique talent.

Stuart Wolf will be moving to Austin, Texas, and we have had a long “heads-up’, as this has been a planned family transition. He will be in on the organizational stages of a new medical school as Associate Chair for Clinical Integration and Operations of the Department of Surgery and Perioperative Care at the Dell Medical School of the University of Texas at Austin.

Austin, Columbus, and Salt Lake City are lucky to get these extraordinary medical talents and superb Michigan people. We will be honoring all 4 faculty at the autumn Nesbit Society Dinner here in Ann Arbor, and hope for a large turnout of alumni and friends.

Ten. Graduation, JOW, & predictions.

Medical school graduation last month in Ann Arbor featured our former dean, Jim Woolliscroft as speaker. You can see a video clip of the lovely event. Jim’s speech offered 7 lessons for the graduates that are well-worth repeating:

Recognize and respect your good fortune that medicine is an inherently meaningful profession.
Patients are not clients – you are not service providers but professionals who share an ancient responsibility to those you serve.
Yours is a healing profession, not primarily a curing profession. Cure is not always possible, but your presence can be valued just as much.
Recognize the individuality of patients. The experiences, comorbidities, and expectations of each is unique. (Jim recalled a patient who taught him that no single patient has, for example, a 20% chance of an outcome or complication – for that patient the chance is zero or 100%).
Making the correct diagnosis is important – don’t jump to conclusions based on what you are familiar with or what’s in your toolkit.
Maintain curiosity and awe of the infinite variety of the human condition. From here on, your patients and your colleagues will be your teachers.
Take care of yourself and your relationships. Make time to reflect.

I especially liked Jim’s fourth lesson and the predictive bearing of statistics on the individual patient. Yogi Berra, in better words than mine, said that predictions are unpredictable. Four years ago, when we were in the midst of another presidential election season, change was also in the air and predictions were no better then than they are today. Jim’s next three points, culminating with reflection, will help your inquiry and critical thinking lead you out of the poppy fields to the right choices of antidisestablishment or disestablishment.

[Taken from my TV October 22, 2012]

If anyone had asked a year ago for predictions of probable high profile medical topics one year hence (i.e., now) Flint, Michigan and the Zika virus would not been at the top of any lists. Yet these topics figure prominently today’s nightly news, daily papers, and top medical journals. Zika, a Flavivirus that injects a single RNA strand into the host cells, was recently discovered to cause acute myelitis, Guillain-Barre, macular atrophy, and microcephaly, for a start. A bite from an infected mosquito (daytime active Aedes aegypti or A. albopictus) gives you a one in five chance of getting the viral infection with headaches, maculopapular rash, fever, malaise, conjunctivitis, and joint or back pains. (Yes, that’s only a 20% chance, but when it’s you that gets the bite it’s all or nothing.) Vaccines are on the way, but until then all you can prescribe is rest and symptomatic treatment. Zika is also spread from mother to fetus, as well as sexually.

As for water security – a single April issue of The Lancet contained articles on toxic water in Flint [The Lancet 387:1499, 2016] and Bangladesh [The Lancet 387:1484, 2016]. These stories are neither random nor coincidental, but part of the growing collective evidence of environmental deterioration and climatic instability. Such issues occupy some of our attention today, but will likely dominate much of the attention of our successors.

So what might we predict for the hot topics one year hence? I would put a major bet down that climatic heat will be a key feature of some of them.

Meanwhile, to help cope with daily change and challenges, good advice comes from the display labeled HOW TO WORK BETTER at the Guggenheim Museum in the exhibit mentioned above by Swiss Artists Peter Fischli & David Weiss.

DO ONE THING AT A TIME

KNOW THE PROBLEM

LEARN TO LISTEN

LEARN TO ASK QUESTIONS

DISTINGUISH SENSE FROM NONSENSE

ACCEPT CHANGE AS INEVITABLE

ADMIT MISTAKES

SAY IT SIMPLE

BE CALM

SMILE

[Texas Hill Country poppy field. Linda Shortliffe, 2016]

Postscript: July 21 (Thursday at 5PM) Chang lecture on Art & Medicine: Don Nakayama, pediatric surgeon, will speak about his unexpected discovery in the Diego Rivera Murals. July 22 9 AM Duckett Lecture in pediatric urology – Caleb Nelson and Lapides Lecture – Bart Grossman.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts May 6, 2016

Posted by dabloom

DAB What’s New May 6, 2016

(3948 words)

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

One. May, at last.

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

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

Three. UMMS graduation.

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

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

[UM Health System 2016]

Four. Role models.

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

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

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

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

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

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

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

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

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

Eight. Harvey & hearts.

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

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

Nine.
One of the pleasures of academic medicine is the chance to visit great centers of excellence and learn from them while teaching residents. I’ve done my share of these tours, and as my career winds down. I don’t expect to be doing many more, but recently enjoyed such a chance to visit Baylor Medical School and friends at Methodist Hospital. Fannin Boulevard in Houston is one of the world’s greatest constellations of health care assets, a tribute to the life and vision of the great cardiac surgeon, Michael DeBakey (1908-2008), role model to thousands of students, trainees, and colleagues. His surgical and educational contributions are unsurpassed in world-wide medicine. DeBakey’s knitting ranged from Dacron grafts to clinical, educational, and research institutions that resulted in the combination of Baylor Medical College, Methodist Hospital, St. Luke’s Hospital, MD Anderson Cancer Hospital, superb urology training programs at Baylor and the University of Texas Houston, Ben Taub Hospital, Hermann Hospital, Texas A&M programs, etc.
The balance was sadly disrupted by governance and leadership blunders, severing the cherished Baylor-Methodist bond. As a result Methodist Hospital of Houston, oddly now, has its academic affiliation with Cornell in Manhattan. The unfortunate story, well recounted in a weblink the residents sent me, could well have been our misfortune at Michigan as one of the perpetrators had been selected by a former UM president and Board of Regents to be our EVPMA, but withdrew in favor of a better deal from Baylor. [Weblink: courtesy Michael Brooks PGY 5 at Baylor- Article in Texas Monthly, March 2005, by M. Schwartz. https://shar.es/1CUXX5 The marriage of Baylor College of Medicine and Methodist Hospital should have been made in heaven—and until recently, it was. Their nasty breakup is a bell tolling for American medicine.]
In spite of the institutional breakup, urologists and their educational programs in Houston get along very well and gave me a great 3-day visit. Edmond T. Gonzales, Jr., the founder of pediatric urology in Houston, had been the first partner of Alan Perlmutter in Detroit. Edmund is a wonderful role model as a pediatric urologist, teacher, and leader. By a rare coincidence he, Ed McGuire, and Jean DeKernion had been on the same dormitory floor as young men in college together in New Orleans.

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

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

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

[Below: Michael DeBakey, museum photo]

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

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

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

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

April First, 2016

Posted by dabloom

DAB What’s New April 1, 2016

Hearts & hoaxes, questions & bells

[matulathoughts.org]

(4073 words)

One. Noteworthy births.

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

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

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

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

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

Two. Happy New Year.

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

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

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

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

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

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

Three. The heavy human footprint.

[USGS Water Science School]

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

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

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

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

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

Four. Ann Arbor notes.

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

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

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

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

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[Below: Dennis Dahlmann & Bill Martin 2015]

Five. Metrics & mission.

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

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

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

[Retreat at Michigan Union]

Six. Bellmen.

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

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

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

Thinking about statements and proofs, a long time ago Pythagoras proved that a² + b² = c²for any right-angled triangle and most of us not only remember this is true, but we can actually prove it by a few examples or tests. A French lawyer and mathematician, Pierre de Fermat (1601-1655), asked himself: if a² + b² = c²then can this be true for higher integers; in other words does a³ + b³ = c³ and is this equation generalizable for all powers? Fermat thought not and his conjecture was written in the margin note of a book in 1637, but his proof was apparently not recorded although he must have convinced himself that Pythagoras’s hypothesis only holds for special cases (like the number 2). For more than 350 years other mathematicians, including Marie-Sophie Germain, tried to figure it out, but failed until Andrew Wiles successfully proved Fermat’s conjecture in 1994.

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

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

Seven. Health care questions.

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

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

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

Eight. Choices.

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

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

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

Nine. An epilogue.

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

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

Ten. Tolling bells.

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

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

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

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

Matula Thoughts March 4, 2016

Posted by dabloom

DAB What’s New March 4, 2016

The March of time, money, & art

3923 words

One. Time flies, but sometimes we have to slow it down. Today would have been March 5, but for a corrective leap year adjustment. This necessity is proof of the slightly imperfect alignment of humans to nature – we meter out our seasons and years with great reliance on lunar and solar cycles, yet our calendars and clocks can’t quite match heavenly reality. Nevertheless, since Robert Hooke’s anchor escape device, human ingenuity has been measuring time with increasing precision. Pocket watches, developed in the 16^th century, were the most common personal timekeepers until military trench watches (pocket watches with lugs for a strap) became popular around WWI, proving more practical than a watch in a soldier’s pocket. The wristwatch quickly came into fashion. Today cellphones threaten wristwatches for top position in personal timekeeping, although wrists are contesting the matter with physical activity trackers that also monitor time, pulse, and even messaging alerts. Whether by wrist, phone, or clock most people are compelled to track time at home and at work. In the health care environment time measurement has come to sharply impact patient care and residency education due to intense attention on clinical throughput and duty hour regulations. [The pocket watch shown above is a rare Donald Mozart three-wheel mechanism watch made over 150 years ago.]

Two. Time is money, it is often said. If I need furnace repairs this winter, a repairman will reacquaint me with that fact. This is also true for legal services, cabs, baby sitters, or employees in your business. Ultimately, because most of us are employees for someone or some organization, we each have a personal stake in the belief that time equates to money. Healthcare used to be somewhat different, being a professional service in which the service was valued as a parcel of work rather than a unit of time. A doctor’s visit, for example, was charged as the actual “visit” with the time factor accounted for indirectly. New knowledge and technology added complex services to the toolkit of health care and the relative value unit (RVU) joined the language of medicine. Urethral catheterization, for example, takes less time and expertise than radical cystectomy, a fact now accounted for in the charges or RVUs. The physician work RVU for catheterization (CPT 51702) is 0.5 (although after facility expenses and malpractice expenses are factored in the total RVU grows to 0.87 to 2.0 depending upon whether the work is done in a hospital or an office). For open radical cystectomy with urinary diversion (CPT 51590) the physician’s work RVU will be 36.33 and the total RVU including facility and malpractice expenses will be 55.66. The assignment of an RVU number to robotic cystectomy is under discussion. Radical cystectomy is one of the most technically difficult and risky operative procedures, with significant mortality, morbidity, complex postoperative care, and the highest postoperative readmission rates. In terms of work (preoperative, operative, postoperative, and global exposure) and liability it is easily more than the “equivalent” of 36.33 urethral catheterizations, in my opinion as someone who has performed both procedures. If it is your urethra getting catheterized, of course you want skill, kindness, and attention to the process. Yet, to equate the effort of 36 catheterizations to a single radical cystectomy is like comparing 36 bicycle rides to flying a Boeing 787 or Airbus A380 full of passengers across the Pacific Ocean. Both take skill and both carry some risk, but the differences are enormous. [Data thanks to Malissa Eversole & Irene Gundle]

Just as all procedures are not equal, neither are all clinic visits the same, although less disparity pertains. One new patient visit may be fairly straightforward with discovery of a simple problem defined as ICD-10 code X and perhaps a distinct solution proposed in the form of CPT code Y. If such simplicity had pertained for all my patients and clinics over the years, life would have been easier although less interesting. Some clinic visits are especially challenging, taking deep concentration and probing examinations and conversations that are not always easy. Occasional clinic encounters are excruciating, with unwilling kids, angry parents, painful social circumstances, and no clear solutions. Yet even these complex occasions are gifts of a sort in that they test our mettle and make the other encounters, by contrast, satisfying and sweet.

Most of us understand the need to steward resources, standardize work as much as possible, and create efficiencies to meet payrolls and manage our mission at large. However, a sharp focus on clinical throughput, with standardized 15-minute encounters and checklists that must be obeyed, runs counter to our values, counter to patient satisfaction, and counter to the excellence we espouse. Still, our eyes stray to clocks on the walls, (although it is a mystery why they are so often wrong) or watches on our wrists, the latter being easier to consult unobtrusively than cell phones and are more accurate than those wall clocks.

Three.

Ben Franklin wrote “time is money” in Advice to a Young Tradesman, written by an old one although the idea has a far older provenance. It is fitting that Ben is featured on our largest circulating currency denomination (since 1969 when larger bills were retired). The Franklin has become the international monetary standard and is worth more than its weight in gold if you figure that the bill weighs around a half a gram and with the price of gold at $1200 per ounce that comes to about $40 per gram or $20 for a Ben Franklin. The US Bureau of Engraving and Printing says that the average C-note remains in circulation about 7.5 years before replacement due to wear and tear. The new bill, with its anti-counterfeiting technology, costs about 12.5 cents to produce, compared to 7.8 cents for the older version (shown above) before 2013. Curiously, and I think dangerously, some people are calling for eliminating this “high” currency note, as humanity seems to be placing its faith in electronic monetary transactions. [Getting rid of big currency notes. NYT Editorial Feb. 22, 2016]

In health care, the concept that time is money applies across all nations and health care systems. In corporate U.S. health care, clinic visits are set in many places at 15 minutes of “face time” with physician, nurse practitioner, or PA. In the NHS of the United Kingdom 10 minutes is a common standard. In third world countries, any such face time might be a rare occasion unless you have cash in hand. Facilities and staff cost money and health care expenses need to be covered by some source, so it seems rational to measure and ration time as well as physical commodities. Facing off against such reality, however, is the nearly universal belief that health care is a natural human right and that its best delivered at the individual level by professions (and, now, teams of professionals).

Time value of money is a financial calculation that dates back to the early days of the School of Salamanca formed by Spanish and Portuguese theologians in northwestern Spain around the first half of the 16th century. (The old city of Salamanca in Castile and León is a UNESCO World Heritage Site.)

Martín de Azpilcueta (1491-1586), pictured above, was an early member of this important school of thought. This Basque canonist and theologian was an innovator of monetarist theory and it was he who allegedly conceptualized the time value of money in the sense that the present value (PV) of a sum of money equals its future value (FV) given a specified rate of return (r) divided by 1 plus r. That is if the Department of Urology gives the University of Michigan Clinical Enterprise $1,000,000 for new capital projects and assumes a rate of return of 7% (the typical interest rate for a savings account in days not so long past) then the FV at 10 years will be $1,700,000, assuming the original sum and the yearly interest returns remain intact. In other words, a million dollars today if invested in those circumstances could be worth 1.7 million dollars in 10 years. Of course, this is not quite as good as that historic savings account at 7% where the interest was compounded annually, in which case the future value at 10 years would be a little over $1,967,000. That is the difference between an annuity and a savings account. Darwinian forces have propelled financial markets to increasingly creative and complex devices, such as credit default swaps that gained recent attention in the film The Big Short, or the more recent contingent convertible bond (CoCo) that exchanges risk for the ability to suspend payment, convert the bond into equity, or write it off totally.

In 1748 Franklin wrote: “Remember that Time is Money. He that can earn Ten Shillings a Day by his Labour, and goes abroad or sits idle one half of that Day, tho’ he spends but Sixpence during his Diversion or Idleness, ought not to reckon That the only Expence; he has really spent, or rather, thrown away Five Shillings besides.” [Courtesy Kate Woodford at Yale University, Papers of Benjamin Franklin Project]

This is the innate paradox of academic medicine: since clinical revenue sustains the enterprise, every part of the day diverted to education, research, and administration is costly, lacking proportionate revenue. Nevertheless, education, research, and their administration are essential to our mission. For a healthy academic clinical department these other parts of the mission consume a minimum of 20% of a clinician’s effort and the ability to support those efforts comes from endowment, institutional support, and the overachievement of clinical faculty in terms of clinical productivity.

Four. As scarce as face-time may be for patients and the professionals who provide it, that time and attention within those moments are polluted by the mandatory processes of electronic health record systems, third party payer requirements, and demands of “meaningful use” documentation. I call your attention once again to the crayon drawing of a doctor’s visit by an 8-year old girl featured on a JAMA cover article in 2012 by Elizabeth Toll and contrast that to any of the many other artistic renderings of this ancient professional service from Renaissance painting to Normal Rockwell. Something seems to have changed. (Interestingly, Rockwell’s family doctor doesn’t seem to be wearing a watch.)

[Above: detail from The Family Doctor by Norman Rockwell 1947; Below: The cost of technology. JAMA 307: 2497, 2012. Elizabeth Toll. © Thomas C. Murphy, MD]

Five. Time piece manufacturing came to Ann Arbor 150 years ago when Donald J. Mozart moved here just after the stockholders of the MoZart Watch Company in Providence, Rhode Island fired him as superintendent. Mozart’s three-wheel watch had proven unsuccessful and the new superintendent replaced Mozart’s design with a conventional movement and renamed the firm the New York Watch Company. Mozart improved his 3-wheel design in Ann Arbor, but was able to produce only about 30 movements before closing up operations four years later in 1870.

He sold the manufacturing equipment to the Rock Island Watch Company for $40,000 cash plus $25,000 in stock and gave away the existing watches to stockholders and friends. One of these was recently sold at auction in NY [Introductory illustration & below: Bonhams Auction 21971 12 June 2014 Lot #1128 A very rare gold filled open face ‘chronometer-lever escapement’ watch Signed Don J. Mozart Patent Dec. 24, 1868. US$ 20,000-25,000].

Mozart was still living in Ann Arbor as of May 14, 1873 when he filed a patent from here, but died four years later in 1877 and was buried at Forest Hill Cemetery (as was Rensis Likert, discussed last month on these pages).

Six. A noteworthy and thoughtful artist, Evelyn Brodzinski, when asked her definition of what constitutes the stuff we call “art” replied, “Art is anything that is choice.” This idea stuck with me and I often quote her at our speaker introductions during the annual Chang Lecture on Art and Medicine each July during the Art Fair. This phrase came to me again when I read Hugh Solomon’s retirement letter this past December. With his retirement, urological manpower loses one of its most excellent physicians and surgeons. Retirement was a difficult decision, Hugh noted, but his timing seemed right: “I have been lucky to have interfaced with so many wonderful people who have taught me the value and sanctity of life. Everyone has a story to tell if you are prepared to listen.”

Stories, however, are getting bypassed in modern healthcare. With the systematic tendency to measure service in terms of time and time in terms of money, today’s electronic health care record systems force stories into checklists. Listening to stories is harder than filling out checklists. While these tendencies chip away at our ancient profession we can fight the trend. When we make a choice to listen, as Hugh advocates, clinical medicine becomes an art.

Seven. Art & medicine. In 1936 Sir Henry Wellcome’s will established the Wellcome Trust in London to advance medical research and the understanding of its history. If you visit that city the Wellcome Trust is a wonderful place to spend a morning or afternoon perusing its collections and exhibits. An article last year in JAMA by Jeremy Farrar, Director of the Wellcome Trust, discussed the role of this organization in the world today. [Farrar. Science, medicine, and society. A view from the Wellcome Trust. JAMA. 313:2315, 2015] The trust expends more than $1 billion dollars yearly in biomedical sciences and biotechnology “interrogating the fundamental processes of life in health and in sickness and using that knowledge to develop ways to promote well-being and to diagnose, treat, or prevent disease.”

Farrar makes the point that while science is essential and wonderful, its implementation in medicine and society is not guaranteed. He references Semmelweis and Snow, who in the mid-nineteenth century provided theory and supporting evidence that certain diseases were transmitted by dirty hands, yet conventional wisdom of the time rejected the idea. Farrar writes: “…their stories reveal that scientific evidence is not enough to improve medicine: social and cultural factors are vital as well… Because the Trust appreciates the importance of the history and social contexts of medicine, it also supports research across the medical humanities, social sciences, and bioethics, as well as funding for artists and educators to engage the public with research.”

We health care professionals revel in science. Scientific ways of thinking have brought us a verifiable understanding of life, health, and illness as well as new technologies to enhance health and mitigate disease. Yet as Farrar tells it, science is not enough. History, social contexts, and values must always frame the science, as well as inspire and deploy it. In the consilience of human knowledge, as EO Wilson explains, science is but one facet of the art of Homo sapiens.

Eight. Chang Lecture on Art & Medicine. In 2007 our Department of Urology began an annual lecture in honor of the family of Dr. Cheng-Yang Chang, an esteemed Nesbit Alumnus who joined our faculty when Urology was a small section of the Surgery Department. Dr. Chang was our first faculty member to focus on pediatric urology. Coincidentally, his father was a highly acclaimed artist in China during its turbulent mid-Twentieth Century years. A number of his paintings are housed in the University of Michigan Art Museum where you can also visit the Shirley Chang Wing, named in honor of Dr. Chang’s late wife. The couple had two sons. Ted Chang, a University of Michigan and Nesbit alumnus like his dad, practices urology in Albany New York. Ted is a first class urologist and educator. Hamilton Chang, a fellow UM man, is an investment banker in Chicago, a leader in Michigan’s alumni organizations and a cornerstone of our urology fundraising efforts.

This year’s Chang Lecture will be given by Don Nakayama, a pediatric surgeon and expert on the Diego Rivera Murals you can find at the Detroit Institute of Art. The Surgery Panel on the upper left hand corner of the south wall has been described by art historians as “brain surgery,” but after personal investigation Don discovered that the art historians were not quite right, anatomically. The actual panel, in fact, depicts an orchiectomy, an operative procedure far more in tune with Rivera’s theme, as a committed socialist, of the emasculated worker. Don discussed this in a paper in The Pharos, [Summer 2014, p. 8].

[Above: south wall. Below: surgery panel]

If you plan to visit the Ann Arbor Art Fairs this July, consider setting aside an hour to join us at the Chang Lecture on Tuesday, July 21 at 5 PM in the UM Hospital Ford Auditorium. You can hear Dr. Nakayama, meet him at a reception after the talk, collect some CME credits if you are a physician, and have your parking ticket stamped. Not a bad deal, I submit.

Nine. The art of humanity extends from the earliest moments of assisting childbirth, caring for lacerations, splinting fractures, counseling sufferers, and painting on cave walls, to today’s robotic surgery and technological entertainments such as the new Star Wars, if you accept the proposition that art is any deliberative human action or construct. This new iteration of Star Wars successfully expands the story of a distant galaxy and the force that binds it. A business school professor at Washington University St. Louis explored the narrative and proposed that an economic force binds the distant galaxy as well, thus brightening the dismal science. [http://arxiv.org/format/1511.09054v1]

The dark side of the dismal science was evident in another current film – The Big Short. I’d read the book by Michael Lewis, who showed in lucid detail how the housing and credit bubble collapse in 2008, known also as the subprime mortgage crisis, was predicted. This catastrophe quickly expanded into a major stall of the world economy, that is still under repair. The astonishing thing is that the prediction was not made by economists, the big banks, the big accounting firms, universities, Nobel Laureates, bond rating companies, regulatory agencies, or “the market” itself. The prediction was made by an oddball physician who analyzed publicly available data and discovered the “obvious” flaw in complex mortgage securities. Astonishingly, none of the experts was so smart and the sad, sad reality is that none of them was doing their job competently. This story begs the question: how can so many smart people be so dumb? It’s an astonishing story and a very cautionary tale of reliance on experts. If course we have to trust experts, but we also have to verify that trust constantly in real time, by listening to diverse and even oddball opinions and insisting upon honest broker regulation and competition.

The physician who figured this out was Michael Burry, a UCLA economics graduate, Vanderbilt MD, and Stanford neurology resident. His main interest, however, was investing and even as a resident had acquired a reputation for success in value investing. He left residency to invest full-time and in November 2000 he started Scion Capital. As Lewis told the story, in the first full year of Scion when the S&P 500 fell 11. 88%, Scion’s fund was up 55%. This was no Bernie Madoff effect, the Scion success was real, verifiable, and durable. Value investing is based on the idea of buying an asset that appears underpriced according to an analysis of some sort. The analysis may recognize some fundamental flaw in the current price of the asset based on historical factors, operational data related to the company, information about its market and competitors, or expectations concerning the future. In some ways this is a complex extension of the thinking of Martín de Azpilcueta. Burry extended the idea by betting against the future value of money through an insurance mechanism called the credit default swap.

Burry was not looking for “a short” rather was actually seeking good long term bets. In 2005, however, his analysis of national lending practices in 2003 and 2004 indicated to him that a subprime mortgage bubble would collapse in 2007. He persuaded Goldman Sachs to sell him credit default swaps against certain subprime deals. The rest is history, as well as excellent cinematography.

[Illustration: Lamro, on Wikipedia, Credit Default Swap. Burry is the blue box, Goldman Sachs is the black box. The par value of the asset was its high value at the time of the credit default deal.]

Ten. March, now that we are a few days into it, has its own stories. March 1 is the meteorological beginning of spring, although that may not be so apparent here in Ann Arbor. March 20/21 is the astronomical beginning of spring in the Northern Hemisphere or autumn in the Southern. The month is named for the Roman God of War, Mars, who was also the guardian of agriculture. This was an odd conjunction since it is not immediately apparent that the pursuits of war and of agriculture are similar. On the other hand, if you believe that the best defense is a strong offense, the idea makes some sense and in Roman times the month Martius marked a new season of farming and military campaigns. In addition to competence on the land and in battle, legend also ascribed to Mars some competence in the urological sense, as his relationship with the Vestal Virgin, Rhea Silvia, produced twin boys, Romulus and Remus, the mythical founders of the city of Rome. Even beyond the reproductive outcome, Mars was generally viewed as a paragon of virility, with no issues of low testosterone. Martius was the start of the Roman yearly calendar until as late as 153 BC. Russia held on to this start date to the end of the 15^th century, and Great Britain and its colonies (even us in America) used March 25 as the beginning of the calendar year until 1752 when the Gregorian calendar was adopted. March is American Red Cross Month.

March 13 marks the shift to Daylight Savings Time. Ben Franklin has been claimed as originator of daylight savings time, but in fact the solid proposal came from George Vernon Hudson who died 70 years ago (5 April 1946). Born in London he moved to New Zealand with his father and became a respected amateur entomologist and astronomer. His daytime job in Wellington as post office clerk gave him time after work to study and collect insects. It was said that this was the impetus for his idea to maximize daylight in winter times. In 1895 he gave a paper at the Wellington Philosophical Society proposing a 2-hour daylight savings time shift. Hudson was a member of the 1907 Sub-Antarctic Islands Scientific Expedition. The daylight savings idea was slow to catch on and New Zealand’s Summertime Act wasn’t passed until 1927.

[Left: Hudson in 1907 on expedition. National Library of New Zealand. Right: Willett in 1909, J. Benjamin Stone Collection, Birmingham Central Library.]

Daylight savings occurred later to another Briton, home builder William Willett (1856-1915). Riding his horse one summer morning he observed many household’s blinds still drawn, indicating the inhabitants were still asleep and missing much of the day. He began to advocate for an official way to extend daylight and the British Summer Time became law in 1916, although Willett died just before it went into effect. (Trivia: Willett’s great-great-grandson is Chris Martin of the band Coldplay.) Today, daylight savings time methods are utilized throughout much of the world.

[Wikipedia. Blue – DST used, Orange – formerly used, Red – never used]

If March came in like a lion we hope it exits sheepishly after a bit of collegiate athletic madness. We also will be having a departmental retreat at the end of the month. Before closing out this message, let me return briefly to Ben Franklin, printer, inventor, author, postmaster, diplomat, and urethral catheter expert. In 1752 he designed a flexible silver catheter for his brother John who was suffering from bladder calculi and it is likely that, living to age 84, Ben used it himself.

Thanks for reading What’s New and Matula Thoughts.

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

Matula Thoughts December 4, 2015

Posted by dabloom

DAB What’s New/Matula Thoughts

December 4, 2015

Paris, Band-Aids, & the coarse emotions of mankind

3140 words

1. December is at hand, although in the busy everyday world of clinical medicine days and seasons seem to blur. Nevertheless, clues abound that make it hard to mistake this holiday month. Above you see the second floor corridor of UM Main Hospital with decorated windows on a previous early weekend December morning. The holiday season has grown from theological roots to a cosmopolitan sensibility of advancing human welfare. This is a time of year we try to think beyond ourselves and the hunger of others is especially compelling whether in front of you on downtown streets of Ann Arbor or in the news reports from the Middle East, Africa, Asia, or South America. Food security is as much, if not more, an essential part of human welfare and health as the specific morbidities that capture our attention as specialists.

Astrologic, seasonal, and meteorological explanations of illness are residues of the more superstitious days of medicine, but with nuggets of truth these links remain in play today. The seasonal and climactic influences on human welfare and health are unquestionably substantial, and as the dinosaurs discovered large extraterrestrial bodies can impact life on Earth. Our bodies down to the cellular level pay attention to calendar, clock, and climate. Illnesses like holidays have seasonality; we know that the incidence and mortality of coronary artery disease peaks in winter and reaches a low in summer while many other conditions also have their own seasons. [Pell JP, Cobb SM. Quarterly J. Med 92:689, 1999] Then, of course, there is the “July effect,” the enduring speculation that it’s risky to be ill in the hospital when new house officers start on the job. Happily today it’s December and all our house officers are well seasoned.

A 1984 music video from the movement called Band Aid “Do they know it’s Christmas?” is a 4-minute classic that is as fresh today as it was 31 years ago – you can find it on YouTube. The supergroup, formed by Bob Geldof of the Irish band Boomtown Rats, raised over $24 million for famine relief in Ethiopia with the video. The most recent incarnation, Band Aid 30, raised funds for 2014 Ebola victims and prevention.

2. We humans, uniquely among all species, are intensely emotional and inquisitive about our health. Healthcare in any season is a matter of attending to small and large problems, from Band Aids to urosepsis 24 hours a day, seven days a week, and each of us needs help from time to time attending to these problems. Victorian novelist George Eliot wrote: “What do we live for, if not to make life less difficult for each other?” This may not be a universal human sentiment, but it surely is a key part of a good physician’s credo and any society must have good physicians. Healthcare workers naturally prefer fixing medical problems and otherwise helping their patients rather than completing electronic medical records or collecting RVUs. Healthcare is also a matter of teaching patients (and learning ourselves) how to live healthier and manage the morbidities and comorbidities of life. We do this work individually, in teams, and across the larger geopolitical world. Tempting as it is, even as specialists in the comfort of our specialized fields, we can’t ignore that larger geopolitical realm. Our urologic cocoon is a fulfilling workspace, yet we have no choice but to also attend to the geopolitical space through curiosity about events around us, by speaking out, and leading when we can. The world is predictably disruptive and explosive, as witnessed just last month in many places from Mali to Paris, the latter more properly an epicenter for peace, as with the Treaty of Paris of 1763 (ending our French and Indian War), the Treaty of 1898 (ending the Spanish American War), and more recent attempts to restore international order.

The 2015 United Nations Climate Change Conference is now meeting in Paris (Nov 30-Dec 11), nearly coincidental in timing to the recent terrorism events. This is the 21st annual meeting of a team that aims to achieve a legally binding and universal international agreement to reduce greenhouse gases and to contain global temperature within 2 degrees Celsius of pre-industrial levels. Forward-looking businesses are starting to recognize the simultaneous necessity and business opportunities of global stewardship.

3. On this day, 4 December, in 1918 President Woodrow Wilson crossed the Atlantic for WWI peace talks in Versailles, a suburb of Paris. That made him the first US president to travel to Europe while in office. After a trip back home for 3 weeks in February he returned to Versailles for the duration of the talks until June. Wilson’s personal physician Cary Grayson accompanied him on both trips and remained with him the whole time in France. The outcome of the talks was the Versailles Treaty of Peace with its inclusion of the League of Nations. Wilson believed in the League of Nations as a hedge against future conflict and on his final return home (shown below) undertook a nationwide tour to campaign for the treaty, but suffered a stroke in October of 1919. Grayson and Mrs. Wilson masked the severity of the stroke from the government and the public, while Senate Republicans opposed the treaty. Henry Cabot Lodge proposed a compromise that Wilson refused. Ultimately the Senate rejected the treaty and the U.S. never joined the League of Nations. Wilson’s internationalism didn’t take hold in the USA, but his efforts were admired internationally with the Nobel Peace Prize in 1919.

Wilson wasn’t at his best in those days with urologic issues in addition to the stroke. Severe benign prostatic hypertrophy (BPH) with urinary retention further hampered his effectiveness as a politician in that critical time. In the days when our Journal of Urology attended to matters of urologic history, an excellent paper by Fogg, Kutikov, Uzzo, and Canter addressed this interlude of Wilson’s health. [J Urol 2011, 186:1153] Historical scrutiny has also revealed Wilson’s paradoxical gaps as a humanist. His racial views and employment decisions, whether as President of Princeton or of the United States, although considered “centrist” for early 20th century America, were strongly bigoted against non-whites and non-Christians. [Berg AS. Wilson. 2013. The case against Woodrow Wilson. New York Times. Editorial November 25, 2015]

4. North of Paris by 24 miles sits the Musée Condé and library at the Château de Chantilly in Oise, housing the manuscript Très Riches Heures du Duc de Berry with its beautifully illustrated monthly panels. The December panel is remarkable. While traditional iconography for the Christmas season would feature a more nostalgic visual, this panel shows the more visceral details of dogs dismembering a boar after a hunt with the Château de Vincennes of Charles V on the horizon and the trees curiously still in leaf (a warm winter?). The castle still stands in that Parisian suburb. The scene, as in all the Duc de Berry illuminations, depicts everyday agrarian life with people going about their daily business. Illness, disability, and intimate details of healthcare, urologic issues most particularly, were too indelicate for such public display, although such aspects of everyday life were real concerns for everyone then as they are today.

Urology has progressed with technology and new knowledge, yet it remains focused on its genitourinary geography, staked out in ancient Egyptian times with urethral catheterization, in Hippocratic days with lithotomy, and in the nineteenth century with cystoscopy. Gone are the days of Frère Jacques Beaulieu, the itinerant lithotomist, who travelled throughout France in the early 18^th century with his “certificates of cure” and removed agonizing bladder stones with his secretive technique. [JP Ganem, CC Carson. J Urol 1999;161:1067]

Nowadays, urologists work in teams and seek innovation for their own practices while freely disseminating their ideas and techniques to others. Urology, at least as much as the other core facets of medical practice, is a social business. President Wilson’s urologic issues would be treated better and more expeditiously today, and even better tomorrow with, perhaps, the histotripsy technology pioneered here in Ann Arbor by Will Roberts and his team of biomedical engineers and radiologists.

5. Like many of our faculty, I’ve been on the road this autumn in that pursuit of new ideas and knowledge, in addition to dealing with the clinical and administrative work flows at home. In Irvine, California at Ralph Clayman’s festschrift I heard state of the art talks on stone disease. Ralph seems glad to be back to the real world of urology after his five years of good service as medical school dean. In Nijmegen, Netherlands I participated in the 50^th anniversary of the excellent Radboud University Medical Center urology unit. Their discovery, education, and clinical work is world-class, and the visit gave me some thoughts related to our impending 100 year anniversary of Michigan Urology. The American College of Surgeons, with its annual meeting in Chicago this fall, is an important avenue of engagement for urologists from the educational, discovery, and public policy perspectives. A visiting professorship in Portland, Oregon game me a chance to see another superb department of urology, formerly headed by John Barry and currently by Chris Amling. My colleague Steve Skoog leads the pediatric urology team, our former medical student Sarah Hecht is performing well there as a resident, and some of our finest Michigan Urology graduates are leading in the regional practice of urology. Steven Steinberg was Michigan’s contribution from the McGuire days here in Ann Arbor and Rou and Jeff are more recent Nesbitonians.

[Nesbit alumni Jeff Wheat and Rou Wang, now of Portland, during my visit]

In Baltimore the 100^th anniversary of the Brady Institute coincided with the Clinical Society meeting hosted by Alan Partin and Pat Walsh. We heard superb presentations from Hopkins faculty, including Ken Pienta (formerly with us in Ann Arbor) and Nobelist Carol Greider who discussed her work on telomeres. She extolled the virtue of “curiosity-driven research” and told how her work was inspired by investigations of Tertrahymena thermophila. (In this odd single celled animal, with only 40,000 chromosomes, the telomere was recognized as tandemly repeated hexanucleotide sequences.) [EH Blackburn, JG Gall. J Molec Biol 1978;120:33] A number of Michigan names showed up in slides of other talks presented in Baltimore: Chinnaiyan, Feng, Tomlins, and Roberts, for example. Hopkins’ new clinical facilities are lovely and functional, yet they have artfully left strong structural remnants of their rich history as a storied urology department.

[Picture: Carol Greider advocating curiosity-driven research and showing slide noting that “New discoveries come from unlikely places”]

6. Ann Arbor’s first snowfall took place this year, somewhat early, on November 21. With winter many plants go dormant and others self-destruct, while most of us animals simply endure the cold and prepare for the next warmer seasons. What’s New, our monthly newsletter, is getting ready for a new calendar year. This communication began in the dean’s office of Allen Lichter around 2001 and morphed into a Urology Department weekly profile of individuals and teams in 2007. On the first Friday of each month we have carved out an issue for my gratuitous thoughts. Nearly 3 years ago we mounted a simultaneous version of the first Friday piece on a blog site and called it Matula Thoughts, with the idea that older pieces could be archived and that the communication could be accessed more easily than email that has become too crowded and too painful a place for most of us to linger. The blog site (wordpress) also allows us to visual the reach of this monthly habit of our Department of Urology.

[Above, 2015 blog visitors, geographic distribution. Below, histogram of last 3 years.]

For me this communication is a periodic Band-Aid for the excessive emails, endless Twitter feeds, and other electronic distractors. Matula Thoughts also provokes curiosity, for example, with the word Band-Aid, that you might consider a brand name. Invented as recently as 1920, the story goes that Earle Dickson (1892-1961), a cotton buyer at Johnson & Johnson, had a wife named Josephine who often cut or burned herself while doing housework and cooking. His handmade prototype (squares of gauze kept in place by crinoline on a roll of tape) allowed Josephine to manage her own wounds. Dickson continued to refine his product and by 1924 the company had a machine that could mass-produce sterile adhesive bandages. With trademark genericization Band-Aid lost its protective status and became a generic term for all adhesive bandages.

[Thank you Wikipedia. Our annual $100 contribution is in your bank for 2015, and no doubt you’ll need another one in 2016. “The Story Behind Band-Aid Brand” Changing Times; The Kiplinger Magazine December 1964: p. 32]

7. In 2016 we will begin a new iteration of administrative structure at the University of Michigan Medical School and Health System. Except for a several year interlude after February 1930 when the regents fired Hugh Cabot as dean (he was Michigan’s founding urologist-educator), the University of Michigan Medical School has always had a dean. On January 1,2016 the duties of the dean will be added directly to the job description of Executive Vice President for Medical Affairs, Marschall Runge. We must thank our outgoing dean, Jim Woolliscroft, for his 8 years in associate dean positions and 9 years of service as dean. Jim has been a superb internist, educator, and statesman of medicine. We hope he will remain with us for in these tricky times and turbulent socioeconomic waters we need his good counsel and intellect. The clinical chairs established an annual lectureship on medical education in Jim’s name and a perpetual full tuition medical student scholarship. [Picture below Jim Woolliscroft and his early mentor and previous chair of Internal Medicine at Michigan, Bill Kelly at the UM vs. MSU game this autumn]

[Picture above: Clinical chairs & Dean Woolliscroft after presentation of Woolliscroft Lectureship and Scholarship]

8. Preview of 2016. I can’t predict much of anything for the upcoming year, other than to say we should expect the unexpected – we should anticipate surprises that may be planetary and in our ecosphere, geopolitical and terroristic, economic, healthcare related, regional, and intramural here at the University of Michigan. We can’t change the occurrence of most of these events, but we can reinforce our values and rehearse our responses. A recent article in Pediatrics by Plant, Barone, Serwint, and Butani called “Taking humanism back to the bedside” concludes with a quotation from George Eliot in Middlemarch that might help reset our humanism thermostats [Pediatrics, 2015; 136:828].

“We do not expect people to be deeply moved by what is not unusual. That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind and perhaps our frames could hardly bear much of it. If we had a keen vision and feeling of all of human life, it would be like hearing the grass grow and the squirrels’ heartbeat, and we should die of that roar which lies on the other side of silence. As it is the quickest of us walk about well wadded with stupidity.”

George Eliot was the pen name of Mary Ann Evans (1819-1880) about whom much more could be said than space now permits. Her only known photograph is an albumen print from around 1865 and held in Paris at the Bibliothèque Nationale.

9. Beaches. On that recent trip to Portland, Oregon as visiting professor, my friend Steve Skoog (former resident of mine at Walter Reed and subsequently our Duckett lecturer here in Ann Arbor) took us to Cannon Beach, where we saw Haystack Rock, shown above. Beaches like this are places to find relaxation, recreation, and inspiration among the waves, seaweed, seagulls, crabs, fish, and bivalves that are doing their daily jobs. We all need moments to unwind and walk around, although perhaps not so obtusely as Eliot believed “well wadded in our stupidity.” For us humans, the beach is expected to be a place of peace, so we are shocked when we encounter perversity there in the form of fatal riptides, tsunamis, the terrifying fiction of Jaws, or real sporadic shark attacks. The predicted rise of the oceans should give us pause as well. Perversity is a word that fits nicely here, meaning something so wrong that it is strange or offensive. Such things are wrongheaded, that is turned away from that which is right or good. Perversity is something that is obstinate in opposing what is reasonable or good. Perversity persistently intrudes on humanity, as we have seen most recently in Paris.

10. By now most people have forgotten Aylan Kurdi the 2-year old boy who drowned with his mother and 4-year old brother in the Mediterranean off the coast of Turkey while fleeing the civil war in their native Syria. Their intended destination was the island of Kos. This was the site of the Hippocratic School of health, education, and the enduring oath 2.5 millennia earlier. Perversely, the bitter irony of the image of Aylan Kurdi lying on a beach to the east 20 miles away is less enduring in our minds than shark attacks in the recent news. Shark attacks on humans occur on an infinitesimally small scale and the Kurdi family tragedy is just one of millions this year alone. How can it be that our brains lead us to fear sharks more than ourselves?

The innocent suffer the most from mankind’s follies such as self-righteous tyrants, political and religious zealots, bigotry, corporate greed, failed national policies, and diplomatic breakdown. The staggering numbers of international refugees (60 million by last count and half of these are children) will exhaust all nations. Any solution to this crisis, if there is to be a solution, is not a matter of expanded quotas in kindly nations. Solution is beyond the ability of any sovereign nation. The solution requires strong international agency that demands national responsibility and accountability, enforces national borders, stewards human future by means of planetary sustainability, and protects the common man above all ideologies, religions, economic theories, biases, and disputes. Wilson’s League of Nations was a valiant, but failed attempt. The United Nations of today is a weak work in progress, although clearly better than nothing as we hope for a favorable outcome of the human experiment. We need some sort of vaccination against the ideological and sectarian viruses for which human brains seem so susceptible. The current crisis of 60 million refugees fleeing civil wars hasn’t been enough to galvanize international response. Greater crises are likely to come from instability of climate, geology, cosmos, and terrorism. With 2016 at hand, we have to hope our species can get its act together soon. While science will provide some tools to that end the essential political solutions will come from educated and humanistic world citizens. Art, in particular, can pull us out of the cocoons of daily life and serve as an antidote to our “well wadded stupidity” for in the words of George Eliot: “That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind.”

Thanks for reading What’s New and Matula Thoughts and best wishes for 2016.

David A. Bloom

Matula Thoughts November 6, 2015

Posted by dabloom

DAB Matula Thoughts November 6, 2015

Seasons, Movember, Nesbit reunion, the dimensions of academic medicine, politics, feline lives, & other disparate thoughts

3452 words

[Self portrait with dog. Nov 8, 2013]

1. Shadows are longer in November, days are colder, and it gets dark noticeably sooner as 2015 winds down. Autumn foliage, so spectacular this season, is detaching from the trees and recycling on the ground. Most of us are getting ready to hunker down and bundle up for the business of winter ahead as we begin to contemplate 2016. We meter out our lives in seasons and cycles, so with November we enter a sort of fin de l’année, playing off on the French term for the end of a century. Fin de siècle most notably applies to the end of the 19^th century, an era around the 1880s and 1890s that was only well understood decades later when historical perspective could account for its significance. The photo below shows Michigan medical students and the hospital in 1880 on a cloudy late autumn day much like today. Their big news would have been the election of James Garfield as president.

[UM Bentley Library. Med students in front of hospital c. 1880]

This was the UM Medical School’s 31st season. The 1880 class, recently graduated, was already practicing medicine throughout the state and beyond. The medical school curriculum had transitioned from a 2-year set of lectures to a 3 and then 4-year program of graduated instruction with laboratory and patient care experience. Today when you walk from our “new” main hospital (it was new in 1986) to the Cancer Center you will pass the class of 1880 picture showing 60 students including 24 women, by my count. Only 4 of the men have moustaches or beards that became so fashionable a decade later (when you continue to view the pictures) and will be more common this month in November due to the world-wide Movember Movement.

A decade later in the 19th century fin de siècle on a similar autumn day these Ann Arbor newsboys are getting ready to hawk the morning papers. That year was midway between presidential elections of Grover Cleveland (first term) and Benjamin Harrison. Newsboys are gone, their jobs made obsolete by technology and nowadays people get their news via NPR, television, or smartphones. Urologists, however, have had Darwinian persistence in the human workforce and technology has actually expanded their reach and role.

Newsboys Pose c 1890

[AA newsboys 1890. I can’t give credit to the photographer who obtained this image without a lot more investigation, but after 135 years I figure this must be “fair use.”]

The medical school and hospital have changed much since then and now in our 167th season the signature educational product of our academic medical center has expanded from medical students alone to include residents and PhDs who collectively outnumber the students two to one. Our mission of education, clinical care, and health care discovery remains unchanged since that fin de siècle, but to fit that mission to today’s world we are re-organizing our medical school and hospital under the single aegis of an Executive President for Medical Affairs and Dean, Marschall Runge. The success of this structural change in terms of the optimization of our mission will depend upon three major variables: the operational details currently under construction, the people selected to execute those details, and the productivity (clinical, educational, and scholarly) of our health care enterprise as a whole.

Political rhetoric continues to heat up this month even though major voting is a year away. The U.S. elections are held on the Tuesday after the first Monday of November and the president is elected in even-numbered years at 4-year intervals, so November 8, 2016 will be a big decision point. The contest today looks stranger than ever with providential outsiders competing against highly seasoned and lightly seasoned professional politicians. The consequences of our elections will roll out to residency training programs, medical record systems, and payment methodologies of the not-so-distant future. More importantly, the consequences will be reflected in geopolitical stability and the international economy.

2. The initial urology experiences for most medical students come during third year rotations and fourth year electives when students take clerkships or subinternships at their home schools and visit other places that attract them. At Michigan we had over 350 actual applications for our 4 residency positions. The applicants are clearly the best of the best, although excellent medical school performance and test scores do not automatically equate to great residents, teammates, superb urologists, and Nesbit alumni. It is our job to transform our selected applicants through 5-6 years of residency and subsequent fellowships into extraordinary urologists, educators, and innovators.

The personal statements of our candidates are articulate, show amazing personal accomplishments, and often reflect on the attractions of urology, especially the ability to fix distinct problems with technical wizardry. Yet, I worry how this generation will do with the distractions of the mounting numbers of comorbidities of patients that complicate their “urology issues.” Will urologic detachment blind our next generation of urologists to the inevitable co-morbidities of their patients? Conversely, will patient comorbidities distract young physicians from urologic-decision making or immobilize them to necessary action? How do we teach our successors to understand and even seek out comorbidities so as to attend to their solutions whilst doing the “urology”? Will the growing administrative burdens, including the mandates of the electronic record and duty hour restrictions, further exacerbate their detachment?

As I was reading transcripts, writing letters of recommendation, and thinking about this new season of applicants, I began to reconsider the characteristics we expect of ourselves as people, physicians, urologists, and educators. Seven key attributes seem to apply equally to residents as well as our best selves. To my list of the seven essential attributes for an excellent urology resident I added a bibliography:

A. Kindness. (P. Ferrucci: The Power of Kindness)

B. Authenticity. You are whom you seem to be. (HG Frankfurt. Two books: On Truth, On Bullshit)

C. Cosmopolitanism (KA Appiah: Cosmopolitanism)

D. Curiosity (EO Wilson: Consilience)

E. Literacy. (S Fish: How to write a sentence)

F. Teamwork & leadership. (DJ Brown: The Boys in the Boat)

My little list may or may not prove useful for a “book club.” Although we don’t have time for this in the 80-hour weeks “allowed” for resident education, perhaps our best trainees will pursue this list or one like it, surreptitiously off the grid, for “extra credit.”

3. Nesbit meeting background. Reed Miller Nesbit was the first official head of urology at Michigan. His teacher, Hugh Cabot, had arrived here in late 1919 to lead the Surgery Department and in short order also became medical school dean. Cabot, a genitourinary surgeon of international stature at this time, was such a catch for the university that the regents gave him the president’s house to live in until he got settled. Nesbit and Charles Huggins were Michigan’s first 2 urology trainees, and Cabot seemed to have trained them well. Cabot’s innovative ideas and outspoken nature offended many and he was fired by the regents in 1930.

Nesbit was then named official head of urology within the Surgery Department and he soon became a pivotal figure in American surgery. Huggins focused on prostate cancer research, developed his career largely at the University of Chicago, and earned a Nobel Prize in 1966. Our Nesbit Society was created in 1972. Faculty, UM urology trainees and UMMS students who got their urology start here, but trained elsewhere, are members of the Nesbit Society.

Residency training is an intense period of work, study, and friendships that reverberate for a lifetime. It is a fact lost on lay people and many in the academe that residency training is the career-defining stage of medical education and the signature product of an academic medical center. It is where the professional knowledge base, values, and skills of the next generation of physicians are forged. Whereas UM has close to 700 medical students and 200 Ph.D.s in health sciences at any time, we have 1200 residents and fellows. [Picture above – day one of Nesbit Meeting 2015 in Sheldon Auditorium; below – day two at North Campus Research Complex]

Nesbit 2015. Our Nesbit academic Thursday & Friday were among the best continuing medical education events I’ve experienced and far too much went on to be summarized here. Attendance topped 100 including Tom Koyanagi from Japan, Dave Bomalaski from Alaska, and Jens Sønksen from Copenhagen, along with many other Nesbit alums and MUSIC colleagues from around Michigan. Faculty, resident, and fellows gave superb presentations. Appropos of November, Daniela Wittmann’s talk included details of the worldwide and Ann Arbor impact of the Movember Movement, including significant scientific funding and collaborations for us in AA. Since 2003, Daniela noted, 5 million Movember participants worldwide have raised over $650 million for men’s health, targeted heavily to prostate cancer. Jerry Andriole, our visiting professor from Washington University in St. Louis, gave superb talks on prostate cancer and PSA.

Greg Harden, our featured speaker, was extraordinary. [Above from left: Gary Faerber, Mike Kozminski, Dave Burks, Greg Harden, DAB] Long-time psychologist to our Athletic Department Greg spoke about need to fine-tune our personal “critical self-assessments” and extended the idea of fitness holistically to the three domains of physical, mental, and spiritual fitness – noting the factor of recovery time: the better fit we are, the quicker our recovery from exercise or exhaustion. During the business meeting Gary Faerber, Associate Chair for Education, announced plans for a new resident’s room. While the hospital is footing the half million dollar overall cost, Gary believed that the dinky regulation lockers and minimal amenities should be upgraded so he announced a campaign for Nesbit alums to fund lockers or computer workstations, etc. Many stepped up to the challenge and Jens Sønksen (picture below; Nesbit 1996 and close colleague of Dana Ohl) put us over the top with an amazing gift.

Julian Wan will be turning over the Nesbit presidency to Mike Kozminski next May at our Nesbit AUA Reception and John Wei will become Secretary-Treasurer. In the Big House Michigan led Michigan State until only the final few seconds when a terrible anti-climactic error cost us the game. No doubt the football team will be doing a thorough post-mortem analysis of that game to look for missed opportunities and analyze mistakes. Just like the rest of the university, the Athletic Department is ultimately an educational unit.

[Opening of UM vs. MSU game 2015. Lloyd Carr is honored]

4. We too analyze our mistakes and untoward events. The Morbidity and Mortality Conference is a key ritual of academic medicine. Once a month we have a 7 AM Grand Rounds-type meeting where our residents stand up and present serious complications and deaths that occurred in our urology department. Faculty and residents discuss what might have been done differently and what factors contributed to each complication or death. Lay readers should not be surprised – every week deaths are likely to occur in UM hospitals at large and among our outpatient population; several million people a year pass through the doors of our health system, tens of thousands of operative procedures occur, and hundreds of thousands of people with serious illnesses are hospitalized. Our daily work is serious, not just the actual care of patients, but also the education of our successors with the expectation that they will be better tomorrow than we are today in this serious business of healthcare. Just as important as patient care and physician education, no less essential is the need to expand the knowledge base of urologic health and disease, in addition to improving therapies and delivery systems. These are the three dimensions of academic medicine. As specialists we hone in with great intensity on the urology issues presented to us, but must also probe efficiently for the context of the urology problem – the comorbidities of health and life.

5. The lives of patients are far more complex than the urologic problems that bring them to our clinics. With specialization comes our conceit of detachment. Living in an era of specialty knowledge and skills, we specialists concentrate on our specific fields and as urologists these are urologic matters. It is easiest to do this in isolation from all the other stuff around a patient’s life, but of course we also need to listen to them and recognize, for example, such things as sadness about recent loss of a parent, delaying traffic jams on the way to appointments, awful parking situations, or perhaps unusual heartburn experienced after a rushed breakfast to get to the appointment on time. These issues are not necessarily irrelevant to, for example, the small renal mass that brings a patient in to see us, although we still need to focus on that immediate issue – and the clock is running while other patients are checking in and you may shortly be called to the OR. On the other side of the coin we have all referred patients with unexplained problems to other services only to be told dismissively by a colleague: “it is not cardiac” or “it is not GI” or “it is not surgical.” We get exasperated when other doctors fail to “consider the whole patient.”

6. Few urological problems, few medical problems of any sort, are isolated conditions. Everyone has lives and comorbidities that complicate the medical conditions under inspection in our clinic. These may be dire social situations, family matters, or other specific medical comorbidities. A recent Perspective in The Lancet by Todd Meyers of the Department of Anthropology at Wayne State University offers a compelling view of this additional dimension of our health care paradigm.

“Comorbidity is a clinical and conceptual problem. It is simultaneously a problem of how to describe multiple morbidities – clinically or epidemiologically – and a problem of how individuals themselves conceptualise and wrestle with their polypathia … Through the play of disorder and circumstance (and presentation and expectation), to treat is to capture, to arrest symptoms in a particular moment, but rarely is there enough time or resource to discover where these symptoms fit within the complex lattice that makes up the individual experience of comorbidity.” [Permission of Todd Meyers. The art of medicine. How is comorbidity lived? T. Meyers. The Lancet. 386:1128-1129, 2015]

You and I will never find the perfect balance between truly understanding a patient in terms of comorbidities of life and body and the immediacy of the person’s urologic condition. The art, however, is in our effort to try as we practice medicine patiently, one patient at a time.

7. Comorbidity, as a term and idea, is attributed to internist and epidemiologist Alvan Feinstein who spent his career at Yale School of Medicine. His reputation has been challenged due to some statements during a period of his career when he minimized the negative effects of smoking, even though he had been sponsored by the industry. [Feinstein, Alvan R. (1970). “The pre-therapeutic classification of co-morbidity in chronic disease”. Journal of Chronic Diseases 23 (7): 455–68] It is easy to pile on indignantly to this criticism now, in 2015, but the overwhelming evidence today of the destructive effects of tobacco smoke was not so apparent back then. Later in his career, particularly as editor of the Journal of Clinical Epidemiology, he became more critical of tobacco. Smoking looked cool in the mid-nineteenth century, and the makers of cigarettes naturally tweaked the composition of their product to enhance the addictive features. Ironically, smoking has turned out to be a major contributor to today’s medical comorbidities.

Feinstein, born in Philadelphia December 4, 1925, died just about 15 years ago (October 25, 2001). He obtained bachelor’s, master’s, and medical degrees at the University of Chicago, where he probably interacted with former UM trainee Professor Charles Huggins. In spite of that likely intersection, Feinstein chose internal medicine for a career and trained at the Rockefeller Institute, becoming board certified in 1955. [Picture from Yale Bulletin & Calendar Nov. 2, 2001] After a few years at what would later become the NYU Langone Medical he moved to Yale in 1962 and became founding director of its Robert Wood Johnson Clinical Scholars Program in 1974.

8. November brings Thanksgiving to mind. The Norman Rockwell painting Freedom from Want (discussed on these pages last March) had its debut on March 6, 1943 as a Saturday Evening Post cover. This was number three in his Four Freedoms series of oil paintings inspired by Franklin Delano Roosevelt’s 1941 State of the Union Address. Rockwell started this particular painting the previous Thanksgiving in 1942, depicting actual friends and family at the table. We are too comfortable today to feel as viscerally about the four freedoms as Roosevelt, Rockwell, and most Americans did during the darkest days of WWII or as the world’s 60 million refugees must feel today, but we should beware that our comfort rests on only a thin veneer of civilization. As specialists we are also sometimes too comfortable in our professions. We enjoy not only the four freedoms of Roosevelt (freedom of speech, freedom of worship, freedom from want, and freedom from fear), but also freedom to choose one’s work, in our case the specialty of urology. Board certifications and hospital credentialing processes define our scopes of practice, while varying degrees of personal detachment allow us to focus specifically on urologic disorders and their treatment.

9. On this particular day in history two now-obscure events left countless social and physical comorbidities reverberating still today. In 1965 Cuba and the United States agreed to an airlift for Cubans who wanted to come to the United States. When the Cuban revolution began in 1959 the U.S. government initially reacted favorably to it, but after hundreds of executions and Fidel Castro’s embrace of communism relations soured and by 1965 the Communist Party was governing Cuba. Amazingly, Castro is still around, having survived as Cuba’s leader parallel to 11 American presidents for 16 terms of office. By 1971, 250,000 Cubans had made use of this program. Only now, 50 years later, do we find signs of improvement in relations with that nation of 11 million people only 90 miles away from Key West, Florida. A second historic coincidence occurred exactly 40 years ago on the other side of the Atlantic. The Green March was a strategic mass demonstration in November 1975, coordinated by the Moroccan government, to force Spain and General Franco (ailing despite recent recovery from a serious bout of phlebitis) to hand over its colony, the disputed, autonomous Spanish Province of Sahara. Some 350,000 Moroccans advanced several miles into the Spanish Sahara territory, escorted by nearly 20,000 Moroccan troops and met very little initial response from either Spanish forces or the Sahrawi Polisario Front, an independence movement backed by Algeria, Libya, and Cuba which was fortified by Soviet arms. The Spanish Armed Forces were asked to hold their fire so as to avoid bloodshed and they removed mines from some previously armed fields. Nevertheless, the events quickly escalated into a fully waged war between Morocco, Mauritania, and the Polisario, once Spain left the territory. The Western Sahara War, as it came to be known, lasted for 16 years. The color green was incorporated to invoke Islam. A cease-fire agreement reached in 1991 remains monitored by the UN Mission for the referendum in Western Sahara (MINURSO). What these two events have in common is the disruption of people’s lives when colonialism, regionalism, and independence movements collide and become playing grounds for larger international proxy conflicts. Sound familiar?

10. November refers to the number nine in Latin, a quantity recalling the alleged lives of a cat. Reflecting back over the shoulder of human time, you can’t help but think that our species has been testing the limits of our existence with far more numerous close calls than a cat’s. The Cuban missile crisis was just one close call, among other instabilities around the planet from Africa, to the mid-East, and in far too many other places. The feline proverb dates back at least to Ben Johnson’s play written in 1598, Every Man in his Humor. William Shakespeare performed in that play and then used a similar phrase a year later in his own play Much Ado About Nothing: “What, courage man! What though care killed a cat, thou hast mettle enough in thee to kill care.” The actual intent of the word care, was worry or sorrow, but somehow over the intervening centuries curiosity became the perpetrator of the cat’s demise. Possibly the belief in 9-lives is related to the ability of cats to land on their feet. In fact their spine is more flexible than that of humans; while like most mammals cats have 7 cervical vertebrae, they have 13 thoracic, 7 lumbar, and 3 sacral vertebrae. We humans have 3-5 caudal vertebrae fused into an internal coccyx, but cats have a variable number of caudal vertebrae in their tail.

[English tabby cat. 1890. Popular Science Monthly Vol. 37]

It is also curious, if we may re-employ the term without penalty, that while cats may have 9 lives and often have amazing moustaches (that remind us of Movember throughout the year), dogs unequivocally remain mankind’s best friends.

Thanks for considering our Matula Thoughts once again.

Best wishes for Movember, 2015.

David A. Bloom

Matula Thoughts October 2, 2015

Posted by dabloom

DAB What’s New October 2, 2015

Change, colors, chloroplasts, mitochondria, & detachment

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1. Michigan’s green landscape is changing now that October is here with the deciduous ritual of autumn colors creeping south at the rate of about 200 miles per week. Autumn colors in Ann Arbor, however, are not just botanic. October brings us deep into the heart of football season when maize and blue attract intense scrutiny. Legend has it that a group of Michigan students decided that the school colors should be azure blue and maize, but school officials didn’t make it official until 1912. Curiously the actual shades of maize and blue differ between the University at large and the Athletic Department.

[Above: Fall colors in Ann Arbor. Big House night game from Craig & Sue Sincock’s box. October 11, 2014. Below: UM seal with distinctive azure blue, courtesy Brad Densen]

2. Physicians once paid great attention to the green world, as plants were a prime source of medicines. This changed in the later 19^th century, when modern medicine evolved with its verifiable conceptual basis of biochemistry, pathology, physiology, microbiology, pharmacology, etc. Before then medications fell into the area of study known as materia medica and botanic knowledge was a necessity for doctors. Leaves are green, by the way, because the dominance of chlorophyll masks out other pigments. As leaves age, green chlorophyll degrades into colorless tetrapyrroles, so that yellow xanthophyll and orange beta-carotene pigments take over visually, although they had been present throughout the leaf life cycle. Red pigments, the anthocyanins, are synthesized de novo as chlorophyll becomes degraded. After the non-green colors show up detachment and recycling of this year’s leaves soon follows.

[Biochemistry refresher: Pyrrole, the five-membered ring shown above (C4H4NH), a colorless volatile liquid, was first detected by F.F. Runge in 1834 as a coal tar derivative. Pyrrole is a component of chlorophyll, other botanic pigments, as well as the red cell porpyrin heme, a co-factor of haemoglobin. Four pyrroles assemble to make up a porphyrin, and these molecules allow numerous color options.]

I happened to see my first leaves of the season fall in early September when I was in Nijmegen, Netherlands at the semi-centennial celebration of the splendid urology unit of Radboud University.

[Above: detachment in Nijmegen 2 weeks ago.

Below: What we look forward to this month: Ann Arbor foliage October 2014.]

3. Change is an apt theme right now as it surely is in the air for health care. Coalescing organizations, new regulations, untried payment systems, intensifying competition, narrow networks, tiered access, new technologies, fantastic and fantastically expensive new drugs, are among the factors behind the unprecedented change. These changes are more than seasonal or market changes and they are putting things that we cherish at risk, namely the three dimensions of academic health care – education, research, and quality clinical care. Clinical care is the primary resource engine for academic health care centers (AMCs). This aspect of our mission is the mitochondria of AMCs, providing not just the context for education and research, but also the bulk of its sustaining funding. Furthermore, clinical care is the moral epi-center and the essential deliverable of AMCs. While American health care is not perfect, it isn’t better in most other places on the globe. Consider the options – in a perfect world how would you manage and fund a piece of society and the economy as necessary, complex, and large as health care? A purely market driven system would leave out a huge chunk of the populace and would not service the interests of the public health at large. Purely governmental systems are perpetually under-resourced, funded at the whim of rotating politicians, bureaucrats, and accountants. Canada, at this moment in time, seems to be the remarkable sole exception to this seemingly natural law. I’ve worked in England’s National Health System (NHS) twice in my life, and am somewhat familiar with its ups and downs, but that natural tendency of impoverished dependence on central governmental funding and accountancy management is inescapable. The NHS was intended to be the exclusive source of health care for the British public, but a growing private sector of health care in the U.K. provides some balance and competition.

4. My friend Karin Muraszko, chair of our Neurosurgery Department, recently gave me a book called Do No Harm by Henry Marsh, a neurosurgeon in London. I read it cover-to-cover and thought it remarkable. The value of appropriate and necessary detachment for a surgeon is one of three things that jumped out at me from the book. The second is that natural law I mentioned whereby a national health system budgeted by politicians and managed by accountants does not serve patients, families, health care workers, or other essential stakeholders well, or kindly. The third point is that duty hour restrictions enforced by national agencies (governments, regulatory organizations, professional groups, or payers) are not conducive to professional education, competence, or expertise, much less excellence. The 48-hour work-week for neurosurgical trainees in Europe might be compatible only with a 15-20 year period of training, but not much less. While a few older surgeons like Henry Marsh are still around, and perhaps an occasional excellent new neurosurgeon might emerge miraculously from the sad current European training paradigm, I fear for the next generation of patients with neurosurgical problems on the other side of the Atlantic. Even more frightening is the thought of the subsequent generations of neurosurgeon-educators that will emerge. For them duty hours, accountancy management, and patient “hand-offs” may trump the sense of professionalism and duty they might vaguely recall having seen in the vanishing breed of Henry Marsh.

5. One of the most important rituals of academic medicine is the selection and education of our successors and just now we are in the midst of this with a new cycle of applicant interviews for our residency. Residency training is the career-defining stage of medical education and one could claim it is the signature educational product of an academic health center, usually exceeding (sometimes by more than twice) the time spent in medical school. I don’t think laymen or our central campus friends fully understand this reality. During our residency training at Michigan young physicians learn the state-of the-art clinical skills of urology, its conceptual basis, professionalism, teamwork, and leadership. They develop the habits of lifelong learning and teaching. When I finished training in general surgery at UCLA, I became a member of the Longmire Society, just as our residents in urology at Michigan become members of the Nesbit Society. The Longmire Society certificate includes a motto that features the words: detachment, method, thoroughness, and humility.

These were presumably the ideal characteristics of a Longmire-type surgeon, and indeed suited “the boss” well. Yet the inclusion of detachment as an ideal characteristic puzzled me at first and didn’t seem quite right as it seemed to imply a lack of compassion and empathy, although I’ve since come to understand the importance of detachment with more subtlety. As I write these thoughts the irony of the term “duty hours” strikes me: duty vs. duty hours. Of course, no one can be “on duty” all the time, but people like Henry Marsh, in addition to their sense of necessary detachment, carry their professional duty with them as best they can throughout their careers day-by-day and night-by-night. The on-and-off duty switch is not flicked frequently. Professionalism, nevertheless, carries with it some danger: we become self-righteous in our jobs and professions. We tend to define the limits of our duty more according to the convenience of our job descriptions than by the needs of the public. This does allow us some detachment, but sometimes more for our own sakes than the sake of those among the public who might want our help or kindness.

6. Change is in the air locally at our own academic health care center in Ann Arbor. We are modestly reorganizing our structure and governance, and a new strategic planning process is in play. As Dwight Eisenhower said: “… plans are worthless, but planning is everything.” (Remarks at the National Defense Executive Reserve Conference. 11/14/1957) We urgently need to figure out how to balance our growing patient population with our mission, with our facilities, and with the changing landscape of health care. At the September 17 Regents Meeting changes were made to our organizational structure that should help us build and execute a strategy that fits us well and secures our success in the brave new world of academic health care. Effective January 1, 2016 Marschall Runge, will add the role of medical dean to his position as Executive Vice President of Medical Affairs. David Spahlinger will become president of the clinical enterprise (a new name for this entity is pending; we have been using the term UM Health System) and Executive Vice Dean of the UMMS for Clinical Affairs. New positions will be recruited for a chief academic officer, a chief scientific officer, and a chief information officer for the academic medical center. A chief value improvement officer has been hired by Dr. Runge. Tony Denton will be the Senior Vice President and COO of the clinical enterprise. [Below: Tony & Marschall] Doug Strong, our former CEO of the hospital and most recently VP for Finance & Business of the University will be retiring after a long run of distinguished service.

7. Born on this day in 1832 was Julius von Sachs, in Breslau, Kingdom of Prussia. We might not be inclined to celebrate his name now 183 years later, but we really should. A curious youngster, probably just like you once were, he had an early interest in natural history, which in 19^th century Europe and North America was the term used for what today we call science. With a Ph.D. from Charles University in Prague in 1856 he embarked on a career in botany. His academic career took him from Dresden to Bonn to Freiburg and then to the University of Würzburg as chair of botany in 1868 where he spent the rest of his career, contributing greatly to the study of plant physiology. He is credited with the discovery of the chloroplast, a subcellular unit in which the chlorophyll pigment packs energy from sunlight into molecules ATP and NADPH while freeing oxygen and producing carbon dioxide. Like mitochondria, chloroplasts have their own DNA and are believed to have been inherited from an ancient ancestor, a photosynthetic cyanobacterium eaten up by ancient eukaryotic cell that happened to be hungry at a certain lucky moment far back in time. A similar moment of ingestion happened somewhere around then when another hungry cell devoured an organism that turned out to be the ancestor of mitochondria, the internal engine for animal cells. Chloroplasts and mitochondria are the resource engines for all life forms beyond the most primitive ones.

8. I have a friend who sometimes says: “Change is inevitable, but progress is optional.” [On Wikipedia the quote is attributed to Tony Robbins, motivational speaker.] Health systems nationally as well as here locally in Michigan are in the midst of change, but we are hopeful that our local changes, here at least, represent progress. The demand for our clinical services in Ann Arbor is growing. I remember not many years ago our health system clinic visits were well under a million a year and we thought we were busy. Our most recent fiscal year (FY 15) produced 2,123,746 visits – representing a 6.1% increase just over the previous year, of which return visits constituted 4.7% and new patients were up 15.3%. The pressure on our exam rooms, faculty, staff, operating rooms, and hospital beds has been painful. We need to manage our health care enterprise better to fulfill the expectations of patients and our community, as well as to enhance our educational and research missions. This cannot be viewed from an accounting mentality as a zero sum game with one mission at the expense of another, but rather as a synergistic triad, with the clinical mission as the moral center, the context for education and research, as well as the prime economic engine.

9. My first box of crayons when I was a toddler offered a half dozen colors and I didn’t notice or imagine at the time that many more colors could exist. If you glance quickly at a rainbow or the light from a prism that’s not such a naïve belief.

[Reflection from a glass door on the floor of my in-law’s house in Waterloo, Iowa. Summer 2015]

However, over time in childhood my crayon boxes got larger with many more colors than I could have imagined. A 64 pack of crayons was astonishing discovery for me.

Nowadays, kids on their iPads can sort through literally thousands of colors. This in turn should be no surprise because on inspection the spectrum of light is not an array of discrete quanta of color variations (at least, not that we know!) – it is in reality a spectrum. This increasing complexity derived from our attention is matched throughout the world today in the increasing number of cable TV channels, the proliferation of presidential candidates, the growing number of health care specialties and focused areas of medical practice, the 10-fold increase medical diagnostic codes effective this year (ICD-10), expanding sectarian conflicts, and gargantuan expansion of worldwide refugees.

10. The 50^th anniversary of Nijmegen Urology was a wonderful celebration they shared with international guests from Japan to Italy to Ann Arbor. It gave me some ideas about the upcoming anniversary of Michigan Academic Urology in 2019. My inclusion in Nijmegen was due to the luck of having Wouter Feitz, their chief pediatric urologist, spend three months with us in Ann Arbor many years ago. Nijmegen, the oldest city in the Netherlands, is situated on the nation’s eastern edge, next to the German border. Radboud Medical University contains a superb urologic unit that happens to be an epicenter of European Urology politically as well as geographically. There, under Frans Debruyne, the European Association of Urology got its start and now, headed by Peter Mulders, the urology unit continues to excel.

[Past & present chairs of Nijmegen Urology. Above: Frans Debruyne. Below: Peter & Cindy Mulders]

The innovative academic celebration was focused around specific patients in the various domains of urology and yet it explored the cutting edges of discovery and therapy. Our pediatric session featured the faculty at Radboud, Wouter Feitz, Barbara Kortmann, Robert De Gier, and Ivo De Blaauw, with Raimund Stein of Mainz and Mannheim along with myself as guests.

[Above: Raimund, Marie Jose & Wout Feitz. Below: Barbara & Robert]

Since our session was on the opening day of the meeting, Wout and I skipped the second day to visit the Mauritius Museum in The Hague, on the western edge of the “Low Country.” The newly restored museum, a lovely historic house in the midst of the complex of government buildings known as the Binnenhof, houses Rembrandt’s great Anatomy Lesson of Nicholas Tulp [below], Vermeer’s Girl with Pearl Earring, and The Goldfinch by Fabritius. These great works and others compel thoughtful attention.

Every year on the third Tuesday of September, which occurred the following week in the nearby Ridderzaal (Great Hall), the King delivers The Speech from the Throne. Wout and I happened to walk by after the room was set up for the event and on public display.

Ridderzaal

[Ridderzaal]

This Dutch tradition is mirrored in the State of the Union address in the United States, and in the annual State of the Medical School speech at our local level in Ann Arbor. Jim Woolliscroft (seen below), our medical school dean performed this task admirably for nearly a decade, just as Allen Lichter had done as our previous dean. Both were great leaders, colleagues, physicians, and educators. They have my greatest admiration for their work in guiding the UMMS through challenging times. Marschall Runge is amply up to the task for our next big steps as an academic health care enterprise in the new combined role.

The trees in the Netherlands during my recent visit had just a few patches of autumn colors, although some leaves had already changed enough to detach and fall.

[Above: tree with patch of yellow. Below: early leaves on the ground near Binnenhof]

From the air as I left the Netherlands the long-lasting and combined effects of those primeval cellular meals of chloroplasts and mitochondria were in full display on the ground below. The green landscape is an obvious credit to the chloroplasts, however the fact that a large percentage of the land, although actually below sea level, is now dry land must be attributed to mitochondrial life forms, especially ours. Thanks to human ingenuity and industry 17% of the Netherlands surface area has been reclaimed from the sea and only 50% of the country’s land is over a meter above sea level. Out of my view from the air and during my brief visit to Holland was the immediate staggering refugee crisis, in Europe below and the world at large. A recent JAMA viewpoint from the UN High Commissioner’s Office on the state of the world’s refugees is worth reading [Spiegel. JAMA 314:445] The UN Refugee Agency counts 60 million forcibly displaced people worldwide at this date and half of them are children. This situation must be charged to the mitochondrial side of the Earth’s ledger and those sorry stories of our failures as a species continue to reshape the planet.

[Syrian toddler – heartbreaking picture from last month’s news compelling our attention or detachment]

Postscript. It’s been a busy month academically and just last week I had the honor of being the Lloyd Visiting Professor in Portland, Oregon as a guest of Steve Skoog, John Barry, and Chris Amling. It is a great, storied department and excellent residents presented complex cases. I was mercifully given most of Friday morning off, allowing me to watch the televised visit of Pope Francis to the September 11 Memorial in NYC. The interfaith prayer service was remarkable with its rich array of colors and beliefs, connected by a shared overarching faith in mankind. The Pope’s presence and his comments offer inspiring counterbalance to the sobering image above and destruction memorialized at the Twin Towers sites. The multicultural colors assembled at that prayer service, symbolizing the rich potential of mitochondrial life and humankind, are the most impressive colors of this autumn.

Thanks for reading What’s New, a posting from the University of Michigan Department of Urology, and Matula Thoughts, its blog version (matulathoughts.org). More on the department can also be found at: medicine.umich.edu/dept/urology.

David A. Bloom

Matula Thoughts September 4, 2015

Posted by dabloom

DAB What’s New/Matula Thoughts September 4, 2015

Labor & laborers: “Individual commitment to a group effort – that is what makes a team work, a society work, a civilization work.” Vince Lombardi

[This monthly email to faculty, residents, staff, alumni, and friends of the University of Michigan Medical School Department of Urology is alternatively published as an email called What’s New]

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1. September returns a serious tone to the calendar and recent world market volatility adds to the sobriety. With vacations over we buckle down to the work of a new academic year in our evolving academic medical center. The fiscal year has already been in play for 2 months and the numbers look good so far.

Screen Shot 2015-08-29 at 11.51.55 AM

Our Faculty Group Practice, now known as the UMMG (UM Medical Group), is figuring out how to deliver the best care we can in nearly 150 Ambulatory Care Units attuned to our other missions (education and research), to our inpatient functions, and to the needs of our environment. The UMMG Board meets monthly and delegates operational details to 4 key committees (Executive Committee, Budget & Finance Committee, Clinical Practice Committee, and the Bylaws Committee). [Picture above: David Spahlinger our Executive Associate Dean for Clinical Affairs and Director of the UMMG with Philippe Sammour, Senior Project Manager UMMG. Picture below: UMMG Board of Directors – August 2015]

The UMMG is a multispecialty group practice of more than 2000 faculty with many other providers and staff in well over a hundred specialties and areas of precisely detailed expertise. The coordination of all these practices among our clinical departments and within our health system at Michigan is a work in progress – and the progress is good. As large as we are, however, we are too small to fulfill the expectations of the patient population we serve today and too small for our research and educational aspirations for tomorrow. Given a steady increase in clinical volume of 6% a year for many years, without infrastructure growth to match, we find ourselves deficient today in terms of clinic facilities, hospital beds, operating rooms (12 short by recent analysis of our daily needs), faculty (at least 250 FTEs short for today’s clinical volume), faculty offices (550 too few today), etc. We also fear that we may be too small to matter in the grand scheme of health care as it is evolving nationally in the face of the Affordable Care Act and the consolidation of networks. In spite of all these problems we are still pretty good compared to our peer institutions as things stand, although modest impending changes in our health system structure and governance will likely bring us much closer to realizing our potential as an unsurpassed integrated health care system and academic medical center – an effective team, a leader, and one of the few truly best. At the University of Michigan we often refer back to our great coach, Bo Schembechler, for his inspiring phrases, notably: “The team, the team, the team.” A fellow great coach, Vince Lombardi who died 45 years ago as of yesterday, echoed some of the ideas of Adam Smith the lead quote this month.

2. September began last Tuesday and meteorological autumn in the Northern Hemisphere starts this month. Farmers traditionally begin the harvest, schools come into session, and the workday, as we noted, becomes a little more serious. Labor Day anticipates the seasonal transition and brings to mind Adam Smith who famously observed (with the examples of the butcher, the brewer, and the baker) that civilization requires specialization of work, although two millennia earlier Hippocrates made a similar recognition that medical practice requires specialization. In the Hippocratic world that first particular brand of work happened to be urology, manifested back then as lithotomy – the cutting for (bladder) stone. Were Hippocrates to visit us today at UMMG in a time machine, the only specialty he would recognize out of the hundred plus areas of practice would be urology – the single specialty he deferred to “specialists of that art.” The knowhow involved with cystolithotomy was rightly described as an art, just as the practice of medicine today is often still called an art. Artists go even further back in time: cave-dwelling paintings, long before Hippocrates, prove visual artists were among the earliest branches of the human labor force.

We previously have commented on the beautiful monthly panels illustrated by the Limbourg brothers in a book of prayers called The Très Riches Heures du Duc de Berry. Brothers Herman, Paul, and Johan were Dutch miniature painters from the city of Nijmegen active in early 15^th century in Europe. Like Diego Rivera, closer to our time, the brothers travelled to the best sponsors who could commission their art. In 1416 the artists and the Duke of Berry died abruptly (likely from a plague pandemic) and their ambitious Très Riches Heures was completed by others. The September panel, shown above, features a harvest with 5 people picking grapes, while a man and pregnant woman seem to be supervising (the managers?). The grapes are placed in baskets, transferred to mules, then moved to oxen carts. Presumably the actual wine-making processes took place within the castle walls along with other trades and crafts. A fair degree of work specialization was evident at the Castle of Saumur there in the France’s Anjou wine region. Worker productivity was of immediate concern to the Duke or whoever was in charge of the castle, with carrot and stick as the time-honored means of motivation.

[February Revolution in Paris at l’Hôtel de Ville. HFE Philippoteaux at Carnavalet Museum]

It was over 500 years later in France before the rights of workers achieved their due attention. The head rolling of the French Revolution was evidence of the disequilibrium between workers and those in charge of them, but it was not until 1864 that French workers obtained a legislated right to strike and in 1866 the right to organize. Louis-Napoleon Bonaparte, nephew of his namesake, was the force behind these workers’ rights. His big moment had come in 1848 when the February French Revolution (an aftershock of the big one in 1789) allowed him to change places in exile in England with the deposed King Louis Philippe who had lost the trust of the citizens. Louis-Napoleon then became France’s first president by popular vote in February, 1848. When his term of office ended in 1852 and he found a second term blocked by the Constitution and Parliament, Louis-Napoleon conveniently organized a coup d’etait, re-naming himself Napoleon III and reigning as Emperor until 1870 (coincidentally wrapping up that term on this calendar day – September 4).

[Napoleon III by A. Cabanet. At Musée du Second Empire. Compiègne]

4. In the heyday of industrialization some types of work were especially dangerous and abusive, although workers had little recourse to ask for safe conditions or fairness. Labor unions arose to occupy the need to balance the worker and employer disequilibrium. Labor Day, to be celebrated next Monday, is a marker for this necessary balance. Forward-looking businesses today embrace the belief that workers themselves are the best source of workplace knowledge and have the best motivation to make better products, with greater efficiency and greater satisfaction for critical stakeholders. This idea is intrinsic to lean process systems that represent the newest evolutionary step in the human labor force. Enlightened leaders have come to realize that the health and happiness of workers are linked to productivity, but more importantly are human rights as well.

Unionization of dangerous occupations makes more sense than unionization of less risky trades – think mine workers versus postal workers – yet, work is work and few can argue that any worker can be abused by any manager or any system. The recent exposé of alleged management abuse of workers at Amazon illustrates this point. Nonetheless, unionization of white collar cognitive professions takes some explanation for, by their very nature, professions have their own intrinsic protections. When professions are commoditized, however, and their members believe themselves treated poorly, unionization becomes a rational step. Unionization of professions might not be necessary in a perfect world, but this world is far from perfect. The Eastern Michigan University faculty are unionized, for example, while the University of Michigan faculty are not. While I am no authority on the EMU story, that particular unionization was likely a direct result of faculty grievances against past administrations. At the University of Michigan, though, the nurses, houses officers, many hospital employees, graduate students, and lecturers are represented by unions. The bottom line is the old story that power has a corruptive tendency and a just equilibrium must exist between labor and management.

[Ann Arbor News, August 12, 2015. The 690 EMU AAUP Professors reach a tentative agreement for annual 2.5% raises, changes in health care payments, administrative support, and research incentives]

Administrators and leaders can become self-important and smug (urology chairs are not immune). In the words of the respected Stanford business professor, Robert I. Sutton, some managers are worse than jerks, if you accept the use of his term in his book title.

[Sutton RI, The No Asshole Rule. 2007 ]

5. All people, governed or managed, need to believe that they are being treated fairly and that their voices are taken seriously by leadership. No employee can expect to agree with all organizational decisions, but an overall sense of fairness and responsiveness to individual opinion must pertain. Fairness is a fundamental human belief, evident too in many of our fellow primates plus some other mammals, but unique for humans among the eusocial species (bees, ants, etc.), as mentioned here last month in regard to E.O. Wilson’s work. Beliefs and language govern us with greater sophistication than the governance by pheromones and patterned behaviors of the other eusocials. We shouldn’t disparage pheromones, however, as they provide colonies the ability to react to observations of its individual members monitoring the challenges and opportunities of the environment. In this way the colony becomes a superorganism. We humans have infinitely greater communication tools to govern and regulate ourselves using facial expressions, noise, language, audible conversations, writing, music, visual art, customs, manners, beliefs, laws, and other ways of conveying information. When the public shares a general perception of fairness, civil harmony is likely to pertain, if not hell can break out. Just as corrosive to society as abusive work, perhaps even worse, is the inability to find work. A few weeks ago I heard the author Walter Mosley being interviewed on NPR by Renee Montagne about his experiences as a 12-year old boy in Watts during the riots of 1965, just 50 years ago. Mosley said, simply: “You could feel the rage” – a statement capturing the raw emotion that exploded on the streets after a young man was arrested for drunk driving. [NPR. Morning Edition. Renee Montagne: Walter Mosley remembers the Watts Riots. August 13, 2015] Ten years after the riots I rotated from UCLA to Martin Luther King, Jr. Hospital in Watts and the effects of the riots were still present physically on the streets and emotionally among the people. My time at MLK was personally and educationally a good experience, I liked the hospital and its gritty esprit d’corps. It was quite a contrast to UCLA’s upscale Westwood campus. The full time staff at MLK felt a part of the community, where the daily struggles were still too often very raw. I didn’t fully understand the rawness then. A new book, Between the World and Me, by Ta-Nehisi Coates however, brings one closer.

6. The first French Revolution of 1789-99 was not the only time in history when it people’s opinions mattered and we see evidence of the power of public opinion again and again. Wise political leaders, administrators, and managers understand that protests, strikes, riots, civil disobedience, or revolutions are unfortunate recourses when public opinion and leadership clash. Political lobbying, referendums, and orderly change of representational governance are more civilized, kinder, and less wasteful. Opinion surveys are another tool to understand stakeholders, with the first documented opinion poll occurring in 1824 when a Pennsylvania “straw poll” found Andrew Jackson leading John Quincy Adams 335 to 169 in the presidential race. Jacksonian democrats thought they had the election in the bag.

[JQ Adams’ daguerreotype c. 1840s; Smithsonian Archives. Although Jackson had more popular votes and expected to win, Adams, a great statesman and politician, gained the support of Henry Clay to win the presidency, serving from 1825 to 1829, when Jackson finally gained the position]

A straw poll is a figure of speech referring to a thin plant stalk held up to the wind of public opinion to see which way it is blowing. George Gallup in Iowa in 1936 added science and statistics to the methodology of opinion sampling. Elmo Roper and Louis Harris entered the field of predictive polling around that time. Perhaps the darkest day for that business was the mistaken prediction of Thomas Dewey’s “defeat” of Harry S Truman in the 1948 presidential election by 5-15 percentage points. Although Gallup explained his error by noting that he concluded polling three weeks before election day, his humiliation endured, demonstrating to us once again that numbers are mere human inventions that may (or may not) approximate reality. All data must be viewed with suspicion, no numbers or numeric manipulations are sacrosanct.

Some thoughts on surveys, but first, a disclaimer: I don’t like spending time on surveys and am quick to delete requests for them in my email. Personal bandwidth in this “age of information” is crowded and in clinical medicine the crowding is especially intense. Last winter I decided to try to list email requests for surveys consecutively over the prospective calendar year, but my effort lasted less than 3 weeks. I gave up after more than 2 dozen such well-intended requests whether from the medical school, the health system, the university, colleagues from other institutions, my professional organizations, etc. The proliferation of surveys, however, is not a bad thing, but rather a reflection of democratic society; others care what we think. Many stakeholders in our work and community want to assess their services to us and hope to discover our opinions of their contributions. The fundamental problem is not their curiosity, but rather our limited bandwidth. No one can satisfy all the requests: you must pick and choose.

7. Just about 50 years ago at this time of year, the Rolling Stones released their hit song “I can’t get no satisfaction.” Written by Mick Jagger and Keith Richards the lyrics referred to sexual frustration and commercialization.

Who would have believed that 50 years later the matter of satisfaction in health care (on the part of patients, providers, and employees) would be major matters of national attention? When I was an associate dean, Gil Omenn and Doug Strong asked me to create a faculty satisfaction survey. After a few reminders, I did this with Skip Campbell, aiming for a very brief set of less than 10 questions to assess satisfaction of the faculty regarding their work and environment. To convince faculty to fill this out we sent out a cogent personal initial request with a few reminders and provided a generous window of time. The response rate turned out quite good. Widespread dissatisfaction was discovered concerning the faculty’s ability to deliver the clinical care they deemed appropriate. This data was an important factor in shaping the transfer of ambulatory care management from the hospital administration to a “faculty group practice.” The information obtained also gave the dean an ability to assess the general “faculty temperature” and understand relative degrees of satisfaction in each department. Since then, the faculty satisfaction survey has been shaped to ascertain more granular information at specific worksites and it has grown in size and complexity. Currently at Michigan we have a number of additional “satisfaction” surveys, but the following ones affect us most directly.

a.) Faculty satisfaction survey. Take this one seriously – it is important to us. Variances from our past numbers or from other departmental data are analyzed carefully by the dean, leadership, and our fellow departments.

b.) Employee satisfaction survey. This gauges how the tens of thousands of employees in the medical school and health system view their work lives and work places. We examine the details at many levels in our administrative hierarchy. The dean also discusses this data with chairs in the yearly evaluation process.

c.) SACUA administrators survey. This comes from the University of Michigan Faculty Senate and queries faculty about their immediate administrators (in our case, this is me) and all the others in the long line to and including the president. Medical School participation in this has generally been weak, perhaps indicating faculty sense of remoteness from the central campus.

d.) Patient satisfaction surveys are increasingly tied to clinical re-imbursement. Initially the UM Health System used Press Ganey surveys of patient encounters. This company has a 30-year history of healthcare experience and the consistency of data was useful for year-to-year comparisons, but we are now constrained to switch to the HCAHPS (Hospital Consumers Assessment of Healthcare Providers and Systems) survey, provided by vendors on behalf of CMS. The change disconnected us from our historic data. HCAHPS queries a random sample of patients 48 hours – 6 weeks after discharge and asks 27 questions related to their hospital experiences.

e.) Those pesky reputation and quality surveys. The US News and World Reports surveys not only rescued a dying newsmagazine, but also galvanized attention and resources of every major health care system and medical school in the country. How do we stand in 2015 national rankings? Our Department of Urology is number 10 nationally.

[Above: Urology Department Spring Retreat, realigning ourselves and listening to each other]

Our Medical School stacks up as #5 for primary care and #10 for research. Our Hospital ranked number 10 in pediatric specialties and number 11 in adult specialties (in spite of our stubborn determination over the past 16 years to avoid joining the “nurse magnet hospital” list).

Recent “quality” ratings such as ProPublica are attracting attention. These low hanging fruits of public data commercialization to date offer incomplete information and lack meaningful context. While these products may have commercial and titillational value, on the scale of meaningful data so far they set the bar at the left end (near zero) of the Likert Scale. By the way, the originator of the Likert Scale, Rensis Likert, was a UM alumnus who died 34 years ago as of yesterday (September 3, 1981) at age 78 of bladder cancer here in Ann Arbor. He is buried at Forest Hill Cemetery, just a short walk from our offices. More on him in a future What’s New/Matula Thoughts.

8. It is wonderful to see a resurgence of high quality labor in Detroit and Shinola is a premier example. Shinola shoe polish originated as a brand in 1907, was trademarked in 1929, and became popular during WWII. Anyone who was in the military then and for a generation thereafter usually had a can of shoe polish at hand because shoes were expected to have a high shine, outside of combat conditions. A spit shine was literally obtained by spit. (When I was in the Army, however, newer permanently glossy black shoes became available and all you had to do was wipe them clean.) During WWII a colorful phrase developed around Shinola, although its author will probably remain forever unknown. The phrase compared Shinola to a bodily output usually more formed than spit, although much less acceptable in public, even at baseball games or on sidewalks. The phrase established a basic measure of intelligence as the ability to discern that aforesaid product of elimination from Shinola shoe polish. The concept was captured beautifully in a scene in the classic film, The Jerk, with Steve Martin. [The Jerk, 1979, Directed by Carl Reiner] Anyway, in 2001 a venture capital firm in Dallas, Bedrock Marketing, acquired the name Shinola and began manufacturing watches, bicycles, the shoe polish, and leather products – all made in America and usually in Detroit. The company also produces a high-quality note pad that, unlike that of most competitors, has paper that doesn’t “bleed” with fountain pen ink. The pads are made here in Ann Arbor by Edwards Brothers-Malloy. Shinola headquarters in Detroit is in an Alfred A. Taubman Building. Of course that building’s name is well represented on our University of Michigan campus and especially in the medical school. Alfred passed away last year after an extraordinary life that continues to impact us so positively on our campus.

In this era of expensive but disposable athletic shoes, the well-shined shoe is less common than in the first Shinola era. My old chief of surgery at UCLA, Bill Longmire, would express visible distaste for sloppiness among his house officers, and sloppy shoes were quick to catch his eyes. Army experience made me an average shoe shiner and I still keep polish and a brush in the office. When I am on the road as a “travelling salesman” on behalf of our department I generally give myself time at the airport to see Rick Jackson, a shoe professional I’ve known for 30 years. Rick is at his job daily opposite gate 47 in Detrot’s McNamara Terminal and one of his chairs is my preferred place to sit and converse while at the airport. Rick also keeps track of fellow traveller urologists, such as Mani Menon. Stop by sometime and let Rick make you look more presentable. [Below: our own Gary Faerber and Dan Hayes of Hematology Oncology with Rick]

10. Historically in the University of Michigan Health System, as well as at most other large health care systems, health care workers labored in disequilibrium with administration. All well-intended specialists in the health care labor force (physicians, nurses, managers, residents, hospital employees, researchers, administrators, unionists, etc.) pushed their agendas, but too often the ultimate agendas of patient care, education, new knowledge, and worker satisfaction were side-tracked. Full and effective faculty participation in the daily management of clinical work as well as strategic planning and deployment was an idea advanced here in the 1990s by Mark Orringer, but soundly rebuffed by the dean and hospital administration back then. The concept had legs, as it might be said, for it is a sensible Darwinian evolution and certainly in tune with the modern industrial ideas of lean process systems. The Faculty Group Practice (FGP) emerged around a decade later and has proven successful in its limited application to our ambulatory (outpatient) activities. In practice, however, the division of clinical work into ambulatory and in-patient spheres is artificial and ultimately counter-productive to our real goals of clinical excellence, safety, efficiency, ideal patient experience, education, new knowledge, and ultimate job satisfaction for all employees. With our current EVPMA, Marschall Runge, we sense new alignment of our health system structure and governance. (Marschall, by the way, is the grandson of a 1918 UMMS alumnus.) The FGP, now the University of Michigan Medical Group (UMMG), hopes to be a cornerstone in the alignment of all essential facets of our academic medical center to fulfill those elusive goals of clinical excellence and mission optimization as mentioned above. We should be able to accomplish this here at Michigan as well or better than any other place on the planet. Our history has set that precedence, our people are as good as they come, and we have, I hope, the collective will and drive to come together and get it done now that September is here.

[Two UM health care laborers, a cardiologist and a gynecologist/obstetrician: Marschall Runge & Tim Johnson]

Best wishes, thanks for reading What’s New/Matula Thoughts and happy Labor Day.

David A. Bloom

	Nancy Rhodes on Expectations and epistolaries
	dabloom on Expectations and epistolaries
	Nancy Rhodes on Expectations and epistolaries
	John Barry on Politics, as usual?
	dabloom on Expectations and epistolaries

matulathoughts

For centuries the matula was a tool to investigate disease. We use this metaphor for our collection of observations and brief essays from David A. Bloom MD, Department of Urology at the University of Michigan.

Nesbit Alumni Society

Matula Thoughts August 5, 2016

Commencement 2016

Matula Thoughts June 3, 2016

Matula Thoughts May 6, 2016

April First, 2016

Matula Thoughts March 4, 2016

Matula Thoughts December 4, 2015

Matula Thoughts November 6, 2015

Matula Thoughts October 2, 2015

Matula Thoughts September 4, 2015