Mays and blues

DAB Matula Thoughts May 4, 2018

Mays, blues, & other thoughts
3855 words

 

One.

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

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

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

 

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

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

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

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

 

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

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

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

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

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

 

Four.

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

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

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

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

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

 

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

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

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

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

 

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

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

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

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

[Below: Jean and Mary DeKernion.]

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

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

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

 

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

[Above: Grady Festschrift group photograph.]

 

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

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

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

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

 

Eight.

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

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

 

Nine.

 

 

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

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

 

 

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

[Above: The Rock.]

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

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

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

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

 

Thanks for reading Matula Thoughts.

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

Spring and all

DAB What’s New Apr 6, 2018

Spring and all

3476 words

 

One.

Spring and All is a collection of work in the early writing career of William Carlos Williams, a New Jersey general practitioner in the first half of the past century. The slim volume is an odd collection of alternating prose and free verse, best known for a poem that begins, “By the road to the contagious hospital…” A recent edition of the work includes an introduction by CD Wright with a phrase comparing Williams to an earlier poet from New Jersey, Walt Whitman. “Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers.” [Spring and All. WC Williams. New Directions Book, 2011.]

Published in 1923, Spring and All came during a time that strained human understanding, juxtaposed between WWI and the Influenza Epidemic that preceded it, and the Great Depression a decade later. Only one year before Spring and All, TS Eliot published The Waste Land, a more obscure and academic poem with complex literary references and snippets of multiple languages. The landscape that Williams presents is not quite so bleak, nor is April (spring) quite so cruel. Still, the Williams terrain is far short of a Disneyland, although some promise is held out as “sluggish dazed spring approaches…” Williams embraced the season cautiously, feeling perhaps some recovery from the recent devastations of war and epidemic, thankfully unaware of the impending economic catastrophe that ran from 1929 through most of the 1930s. In much of the work Williams conveys an ominous sense of mankind’s tendency toward self-destruction. [Above: by the path to the Frankel Cardiovascular Center; below, Williams, Wikipedia.]

Whatever constraints the world may bring to bear, spring is generally a season of optimism and refreshment. After a rough winter in much of the northern hemisphere including North America, Europe, Russia, Japan, and Korea, we are glad for spring and all it brings.

[Above: Signs of spring at home, early daffodil and tiny blue flowers sprouting with a few flecks of overnight snow. April, 1, 2018.]

 

Two.

We pursue that idea of a “great human understanding” in the practice of medicine, an understanding never fully realized, but one that grows even as challenged by the practicalities of each day and the idiosyncrasies of each patient. Physicians “take histories” and examine evidence in pursuit of authentic narratives that allow them to understand the conditions and needs of their patients.

Using the phrase, the practice of medicine, the final word medicine seems increasingly parochial and archaic. In this era of specialty healthcare, “the team” has supplanted the solo practitioner and the term medicine, implies a drug or a specific branch of learning and practice itself more than encompassing all of healthcare. Reference to the practice of medicine is parochial in that it excludes other essential practitioners or binds them up within the terminology of my branch of healthcare.

Yet, the practice of medicine has a comforting ring to it, recalling Hippocratic times when the practitioner’s responsibilities were outlined in a sacred oath and the profession of medicine was as much art as science (observation and reasoning). The historic sense of the professional calling of a doctor tending to a patient worked well up through much of the last century, exemplified by horse and buggy house calls, Norman Rockwell’s depictions, Albert Schweitzer’s humanitarian work, and Marcus Welby’s television dramatizations. The one-on-one relationship of a practitioner to a patient is still essential to excellent healthcare and it is a relationship that offers magical moments for greater human understanding. The dilemma in modern healthcare is that this special duality must find a place within the great tent of the team.

These last thoughts beg a big question – do our students and successors understand the earlier eras of healthcare that today’s healthcare is predicated upon?  Do they know who Hippocrates, Galen, Avicenna, and Lister were, or what they achieved? Do our students know of Norman Rockwell, Albert Schweitzer, or Marcus Welby? Should they know these things and how would they know of them? Today’s medical education, indeed all of healthcare education, falls short of the mark in teaching the history and context of healthcare. To some degree this should have been the job of higher education (we used to call it liberal education), but the need in medical school and residency education is even more acute. Without history and context, it’s hard to find values that are so essential to human understanding.

 

Three.         

Morel quandaries. Spring is morel time in Michigan. These wild and mysterious mushrooms defy all human efforts to cultivate and industrialize them. Experienced mushroom hunters, such as our friend and neighbor Mike Hommel, are skilled at finding and accurately identifying morels, and there are few things better on the palate than the end result of his searches.

[Above & below: morels]

Mushrooms, although not morels, play a pivotal role in the current film, Phantom Thread, but no more should be said for those who have yet to see this strangely elegant period piece and psycho-drama.

The morel (genus Morchella) evolved from a yeast only as recently as 20,000 years ago, according to some authorities, although others claim it is an ancient cup fungus as old as 129 million years (at this point, science has only deepened the mystery). Many morel species exist, perhaps 60, having distinctive and highly polymorphic honeycomb configuration allowing effective camouflage as pine cones. Morels have some relationship to recent fires and decaying fruit trees, but the exact formula of conditions for them to prosper remains elusive. The morel supports a multimillion dollar industry business of hunting and gathering. Had William Carlos Williams ever experienced morels, they surely would have figured in his Spring and All landscape: “Beyond, the waste of broad, muddy fields brown with dried weeds, standing and fallen patches of standing water the scattering of tall trees…” Morels are of some spring’s mysterious marginalia, happy little surprises of the season and all.

 

Four.

Daily practicalities confront and confound everyone, navigating their lives and work, and physicians do not get a free pass from them. In the horse and buggy era, a house call was no easy matter, given the inertia to leave a comfortable home at inconvenient moments, saddle up horse and a buggy, and then set off to the patient’s home. Electronic medical records among many other systemic constraints offer newer barriers to many practitioners today, and even those facile with keyboard medicine find they have traded spontaneous interactions with patients for new formulaic work flows of check lists, drop down menus, smart sets, and the lure of cutting and pasting.

Patients as well as healthcare providers must also deal with modern daily practicalities that are impracticalities, more often than not. Matters of finding time from work, transportation, parking, insurance forms, questioning at front desks, forms to fill out, and the incessant repetition of one’s story to an array of healthcare workers dampens the spirit of the human soul. Yet, an ultimate audience with a single healthcare provider (I use this more inclusive term because there are a number of categories of us) is usually a moment of immeasurable importance for patients, who are hopeful for someone to listen carefully to their narratives and gain an authentic understanding of their stories, their histories, instead of processing them into checklists and pre-written sentences and dot-phrases.

 

Five.

Williams began Spring and All with an admission of mixed optimism and inadequacy as a writer:

“If anything of moment results – so much the better. And so much the more likely will it be that no one will want to see it.”

Writers are vulnerable to mistakes and criticism of their work (criticism of themselves as people!) comes with the territory. Writers must accept that they will make mistakes and that some readers in their audience will find their work erroneous in parts or lacking in other ways. It may sting when errors are discovered, but that is a good thing in that correction (peer review, if you will) makes the product better and sharpens the writer’s own fact-checking and proof-reading going forward.

Criticism of style, argument, or quality of thought is a more painful challenge. Good criticism can sharpen an author, although some criticism will be wrong, misdirected, or even malicious. A writer has to hear it all, in the hope of learning and fine-tuning the craft of thinking and writing. Williams, in his writings, put himself “out there” for the world to inspect, criticize, fault, or praise. Some factor in his psyche compelled this expression of art, a factor closely tied to the art of his medical practice.

Spring and All is a quirky and complex collection of prose and poetry. Williams was around 40 years old when this was published and no sensitive novice. Yet he opened the work by admitting that he was not fully up to the task of appreciating and expressing that “great human understanding.” Furthermore, he revealed his vulnerability to criticism.

“There is a constant barrier between the reader and his consciousness of immediate contact with the world. If there is an ocean it is here. Or rather, the whole world is between: Yesterday, Tomorrow, Europe, Asia, Africa, – all things removed and impossible, the tower of the church at Seville, the Parthenon.

What do they mean when they say: ‘I do not like your poems; you have no faith whatsoever. You seem never to have suffered nor, in fact, to have felt anything very deeply…’”

Williams, like other physician-writers, double dip into the conundrum of human understanding in that they are simultaneously medical practitioners and writers, allowing each craft to fuel the other. It is astonishing that we don’t embrace the study of major physician-writers like Williams during medical training with the rigor that we rightly insist upon for other relevant topics such as genetics and pharmacology.

 

Six.

Hall of corrections. Last month I did a disservice to John Hall (Nesbit 1970), misattributing his practice to the Traverse City area, when in fact he worked in Petoskey. Ward Gillett (Nesbit 1985) set me straight. On the other hand, Tom Hall (Cleveland Clinic), who passed away in 2002 practiced urology in Traverse City, and Bob Hall (Wayne State University) also practiced urology in Traverse City. None of these urologists is directly related, although they and I and you are all cousins, according to a quirky book, It’s All Relative, by AJ Jacobs, who writes that all humans go back in time 8,000 great grandparents ago to a common pair of human ancestors who “hunted, gathered, and vigorously reproduced on the plains of Africa about 200,000 years ago.” [AJ Jacobs It’s All Relative, Simon & Shuster, 2017. P. xi.]

John Hall trained here at the University of Michigan exactly at the mid-point in our urology centenary and reminds me that he is thus the “fulcrum” of the Michigan Urology story. Knowledge and technology changed urology over the course of its century, but our mission and values have been constant and will likely remain so in the next iteration of departmental leadership.

 

Seven.

Blind eye. On an April day in 1801, a few days earlier in the month than today, the Battle of Copenhagen launched an enduring metaphor. The phrase of turning a blind eye is attributed to Admiral Horatio Nelson, of the British Royal Navy who had been blinded in one eye earlier in his career. The story goes that during the April Battle in 1801 his superior admiral, the cautious Sir Hyde Parker in charge of the overall battle and sensing defeat, signaled Nelson’s forces to discontinue their action. Nelson was a subordinate but more aggressive admiral and when told of the signal flag message, lifted a telescope to his blind eye and claimed that he did not see an order to desist. [Above: Nicholas Pocock, The Battle of Copenhagen, 2 April 1801, Wikipedia.]

The metaphor took on a life of its own and today would come to be called a meme – an idea, image, or behavior that spreads in a biologic fashion like a gene, replicating and modifying itself within and across cultures and times. The meme neologism is a contribution of Richard Dawkins, worth discussing at a later time.

Blind Eye is the title of a book by James Stewart, an investigation of the true story of a young physician who, for likely psychopathic reasons, poisoned or otherwise killed hundreds of patients and others until apprehended by the FBI. The title comes from the educators in academic medicine who turned blind eyes to his aberrant behavior. That story closely mirrors an earlier true story of a physician, involving Michigan Medical School graduate Edward Mudgett of the class of 1884, who went to Chicago after getting his MD, changed his name to HH Holmes and similarly dispatched scores of people for personal gain or oddly-derived pleasure. Eric Larson told that story in bestselling book, Devil in White City. I read both cautionary tales during a dark interlude in our own Michigan Urology story 20 years ago. Since Admiral Nelson, the phrase has become ubiquitous in English, you can hear it used early in the film, Black Panther.

 

Eight.

Certainties in life, April 15 for example. The author of the phrase claiming only two things are certain in life may never be known, but this is an obvious and nearly universal belief, cynical as it is. Most of us can’t seem to get around taxes, this month most particularly, and none of us will avoid the other absolute. Mortality always trumps economics.

It’s easier to confront economic issues than the mortal one and for an economist, life is viewed from the perspective of supply and demand tensions and balance sheets. Everything else, outside the economic issues, is a matter of “externalities.” The problem with economic models is that most of what really matters to people in the real world is reduced to those externalities. One can argue that Adam Smith’s book, An Inquiry into the Nature and Causes of the Wealth of Nations, suggested that economic wealth derived from all the externalities of the people, social groups, and markets working together. Economic wealth cannot be isolated from the externalities that create it.

Wealth of Nations was published in 1776, but Smith’s more astonishing book, The Theory of Moral Sentiments, came earlier in his career, in 1759 when he was only 36 years old. Permit a repetition here of the signature thought from that work.

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

Smith’s belief in mankind’s better nature preceded and likely superseded his ideas about the wealth of nations and the human economic model that today would be described as homo economicus, wherein human choices are primarily those of self-interest in daily life and in commercial markets, as he justifies in the following quote from the 1776 book.

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

Differing ideologies can exist harmoniously in the head of one person because human life is complex and not reduced to simple models. Its daily practicalities demand both functioning markets of commerce, where self-interest can rule the day if rules and opportunities are fair, existing on a bed of humanity anchored by kindness, kinship, and other characteristics of human civilization that have defined our species and allowed it to grow.

 

Nine.

            Spring, now and then. Emerging from a challenging winter, spring brings welcome change. When the general practitioner from Patterson, New Jersey published his collection in 1923, the specialties of medicine, the specialties of all of healthcare, were just starting to express themselves. Simultaneously serving as Dean of the Medical School, Professor and Chief of Surgery, and the University of Michigan urologist, Hugh Cabot was building a 1000 bed university hospital that would define the emerging medical specialties and initiate a urology residency training program that would come into fruition three years later with Charles Huggins and Reed Nesbit as Michigan’s first urology trainees.

After Cabot was fired by the Regents in 1930, Nesbit expanded the training program and would train 77 individuals including Jack Lapides who trained an additional 64. McGuire continued the process, for another 42 residents and fellows. Intervals of Bart Grossman and Joe Oesterling followed with another 8 and 16 trainees. Jim Montie, who led Michigan Urology to departmental status, trained 47 and with our graduation this spring 41 residents and 34 fellows will have been trained here under the present era of leadership, at last count. At this point I don’t know if Cabot trained any others besides Reed Nesbit and Charles Huggins, so the count of Michigan urology trainees stands at 329 to date.

This July a new set of residents and fellows will continue the traditional of urology education in Ann Arbor.  The residents will be: Kathryn Marchetti of the University of Michigan, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Our new fellows will be: Guilia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO).

Our new residents will complete their program in 2023, a full century after the spring of William Carlos Williams. They will continue a path of medical service that began well before Hippocrates. In their own careers and in their own unique fashions they will follow William Carlos Williams in search of a greater human understanding to alleviate illness and suffering. Evolving therapeutic tools, as attractive and incredible as they are, will always be secondary to the human understanding that deploys or restrains them. We hope to inspire the class of 2023 and our fellows to grow their capacities for human understanding just as they grow their knowledge and skills throughout their careers. That understanding will never be complete, but it can grow experientially, patient-by-patient, and humanely without being co-opted by the formulaic encounters of electronic medical record and artificial intelligence systems.

 

Ten.

Art Can Help is the name of a short book I recently found in Washington, DC, at the National Gallery of Art. With summer and our annual Chang Lecture on Art and Medicine (Thursday, July 19) soon ahead, I couldn’t resist the purchase. The author, Robert Adams, is a well-respected photographer and a superb writer and critic (photo below, Wikipedia). Coincidentally, like Williams, he came from New Jersey. This little volume is a series of short essays on a number of photographs, but is introduced by comments on two familiar Edward Hopper paintings. The title is provocative – help what, help how? Clearly the answer is up to the reader, but as I processed the book, it seemed that Adams intended to show how art (visual art, in this case) brings us closer to that great human understanding. It is a book I’ll return to, adding more and more marginalia and end-page references. [Art Can Help. Yale University Press, 2017.]

Let me close this monthly essay with two passages from Adams, reproduced with his permission.

            “Edward Hopper’s Early Sunday Morning is a picture upon which to depend. It is affirmative but does not promise happiness. It is calm but acknowledges our failures. It is beautiful but refers to beauty beyond our making.”

These four sentences offer an astonishing take on a well-known image, offering the ideas of depending on a picture, finding affirmation and calmness, the slightly buried idea of truth (not promising happiness, acknowledging failures), and the concept of beauty. Adams reminded me of a line in Spring and All by Williams: “so much depends upon a red wheel barrow.”

Toward the end of the book Adams inspects work by American photographer Anthony Hernandez, invokes the name of another great photographer from an earlier era, and affirms the importance of our choice to care:

            “Alfred Stieglitz said that ‘all true things are equal to one another’, and in that he spoke for most artists. They are convinced, despite having to sort through daily practicalities by triage, that everything is of immeasurable consequence…

For Anthony Hernandez, everything really means everything – a chair made of broken drywall, a fishing place where one might not want to eat the catch, a platinum-colored wig, … and everything means everyone – a woman with flowers in her hair, a man with a boxer’s broken face, an officer worker alone at noon with a book…

Why on the evidence of pictures is everything important?

First, because we are part of it all … our part being to be blessed with language that enables us to stand outside ourselves and make choices. We can choose to be caring.”

 

[Window box, Tradd Street, Charleston, SC.]

Thanks for reading Matula Thoughts this April, 2018.

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

 

Matula Thoughts June 2, 2017.

Qualification, adaptations, & stories

3876 words

 

 

One.  

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

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

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


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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

 

Five.

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

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

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

 

Six.    

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

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

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

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

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

 

Seven.

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

 

Postscript

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

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

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

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

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

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

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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

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


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


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

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

March Thoughts

DAB What’s New March 3, 2017

March Thoughts

3741 words

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

 

the_victors_sheet_music

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

or

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

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

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

louis_elbel

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

march

 

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

cave_painting_l

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

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

the-she-wolf

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

 

Three.

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

george_w-_johnson_1898

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

berlinerdisc1897

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

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

jackie_brenston-1

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

 

Four.

1949_oldsmobile_88

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

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

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

 

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

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

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

440px-muenchhausen_herrfurth_7_500x789

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

 

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

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

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

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

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

 

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

sterns-2012

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

 

Eight.

metro

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

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

 

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

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

 

Ten.

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

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

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

————————————————————–

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

734-232-4943

dabloom@umich.edu

 

Matula Thoughts June 3, 2016

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

 Matula_Logo1

 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.

 

Screen Shot 2016-05-29 at 8.22.24 AM

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]

JM Award

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.

Montie, Straffon

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 16

[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).

McLarens

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

Zuckermans


Jens, Dana

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

Screen Shot 2016-05-29 at 8.33.55 AM

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.

Barry & Parry

[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

[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 18th 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 19th 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 field

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.

WizardofOz_poppies

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.

Poppies 2010

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 18th century Stockholm .

Screen Shot 2016-04-10 at 5.05.23 PM

[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.

cerny

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

Gordon

Tom & Sharon 2013 copy

Steers

Adrian

 

 

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

Gary F

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.

Lee, Cheryl

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.

Oldendorf

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.

Wolfs

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.

JOW

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.

Screen Shot 2016-05-29 at 8.52.34 AM

[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

Shortliffe poppies

[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