Origin stories

WN/MT July 3, 2020
Origin stories
2518 words



One.

Hunkering down this spring, we explored Ann Arbor’s Water Hill neighborhood during social-distanced walks and saw flags that anticipated the Fourth of July. Tomorrow’s holiday brings to mind Danielle Allen’s book, Our Declaration. The American national origin story centers around a representative democracy formed disruptively when 13 colony-states spun off from a parliamentary monarchy. Even at the start, the story was complicated by the colonial expropriation of lands from their indigenous inhabitants and enslavement of abducted Africans to build the economy. These matters remain unreconciled, and so some Americans today will display the flag upside down, take a knee, or illuminate irreconciliation in other ways.

As the number of states increased in America, state sovereignty contested federal authority over a variety of issues amidst economic crises, wars, environmental catastrophes, epidemics, and paradigm shifts in technology. Life got more complex with technology, subspecialization, regional interdependency, and the sheer scale of rising population. Many matters transcended state boundaries and demanded federal solutions. Consider, for example, a public debate in 1820 on the role of federal government in matters of personal health, public health, medical licensure, specialty certification, and health care economics versus a similar debate today. The debaters in 1820 would have scratched their heads wondering what possible business the government could claim in such issues, except possibly a limited responsibility for public health.

The basic Jeffersonian aspirations within the Declaration, however, seem to hold true and anchor most of the attempted solutions to the nation’s big and little problems. Those personal aspirations – life, liberty, and the pursuit of happiness – bear repetition, especially now in July, 2020. It now takes great rhetorical acrobatics to discount the role of equitable public and personal health care in life, liberty, and the pursuit of happiness in today’s complex world. A debate in 2020 over the roles of federal government in matters of personal health, public health, medical licensure, specialty certification, and health care economics would be quite different than that imagined debate of 1820.

One big effect of this pandemic may be that the public may find a way to build a new vision of government “by the people and for the people” that will fine-tune the aspiration of “life, liberty, and the pursuit of happiness” to the complexities of 21st century civilization. Governmental responsibility for “life, liberty, and the pursuit of happiness” entails securities of personal freedoms, food, and employment, as well as public safety and public health. Any line placed between public health and personal health, or between public safety and personal safety is an arbitrary choice. These basic securities should be expected of any state or society, worthy of the term civilization.


Two.

Baseball comes to mind now, but this season is off to a slow start, if it happens at all. So meanwhile, a bit of time travel to the past is in order: a little more than ninety years ago (May, 1930) Ty Cobb threw out the first pitch at a new baseball park in Hamtramck, Michigan. [Picture below: 1928 International Newsreel photograph of Lou Gehrig on left, Tris Speaker, Ty Cobb, & Babe Ruth taken in April 1928.]

Cobb was a national celebrity who had retired from the Detroit Tigers in 1928 after 22 seasons and came back for opening day at Hamtramck, although he never actually played a game there. The new stadium, replacing Mack Park, would serve as one of the historic Negro League venues through 1951.

Mack Park had been home to the Detroit Stars, but after the grandstand burned down in 1929 the venue was relocated to the Hamtramck site, opening in May 1930. The Detroit Wolves took over for the Stars, in a new East-West league in 1932, but folded in the unfavorable economic times. The Detroit Stars was resurrected in 1933, but lasted only one more season at Hamtramck, that then lay empty. The Stars had a third life in 1937, but that too lasted only one more season. Detroit city acquired Hamtramck Stadium in 1940 and renovated it through Roosevelt’s Works Progress Administration as part of a larger Veterans Park project. Hamtramck Stadium has since hosted high school and Little League games, but after 2012 it fell into disrepair and neglect. Of the 12 remaining Negro League stadiums only Hinchliffe Stadium in Paterson, New Jersey and Rickwood Field in Birmingham, Alabama were in use longer than Hamtramck.

Michigan has some puzzling names, in that the historic contexts of their origins have been lost to most people today. Hamtramck, more than most American communities, reflects dominating effects of immigration and displacement of native people. [Below: Site marker installed August 2014.]



Three.

Hamtramck, a tiny city surrounded by Detroit, had little commonality with Ann Arbor, only 44 miles away, in that spring of 1930 when the University of Michigan Medical School was reeling from the firing of Hugh Cabot in February as dean and chief of surgery. No dean would replace him for three years and the school’s executive committee assumed the role of dean. Frederick Coller was named chair of surgery and appointed Reed Nesbit as the head of urology, but he was a “head” with a single deputy. It’s unlikely that Nesbit and the University of Michigan community knew much about Hamtramck Stadium when it opened that May 1930, although Nesbit became a devoted fan of the Detroit Tigers and certainly knew the name, Ty Cobb. Hamtramck Stadium would become one of the important Negro League venues and is listed on the National Register of Historic Places. [Below: Col. John Francis Hamtramck takes possession of Fort Lernout, part of mural at Detroit Water Building. Wikipedia.]

Jean-Francois Hamtramck (1756-1803), a French-Canadian soldier born in Montreal, came south to join the Continental Army and became a decorated officer in the Revolutionary War. He then served in the Northwest Indian War, displacing native American communities, and was the first commandant of Fort Wayne (Indiana). In 1796 he transferred to Fort Lernoult and the settlement of Detroit, where he died seven years later.

The Jay Treaty, designed by Alexander Hamilton and negotiated by John Jay in 1794, had ceded the fort from Britain to the United States effective 1796, when Col. Hamtramck moved there with 300 troops. Britain reclaimed the fort, by then named Fort Detroit, in the War of 1812. After the Battle of Lake Erie, the fort was returned to the U.S. and renamed Fort Shelby. In the aftermath of this and the Northwest Ordinance Act, territorial judge Augustus Woodward came to Detroit from Virginia with radical ideas on education that he deployed in the University of Michigania in 1817.

The town within Detroit that took Hamtramck’s name began as a farming community of German immigrants and incorporated as a village in 1901. There, the burgeoning Detroit Stove Works attracted industrial workers and shifted the demography from rural farmers to immigrant urban factory workers. By 1910 the Dodge Main Assembly Plant dominated the town, attracting new immigrants and within 20 years the town became heavily Polish and middle class. Of the thousands of factory workers in the 1920s, nearly 80% owned or were buying their own homes. Attracting a new generation of different immigrants, the town (2 square miles and 23,000 people) is now the most densely-populated and most ethnically diverse in the state and in 2015 became the first in the United States to elect a Muslim-majority city council.


Four.

Lessons of history. Each season brings particular infectious risks and in those days when Ty Cobb threw out that opening pitch at Hamtramck 90 years ago, parents were anxious about the summertime threat of polio to their children. Much less commonly, “infantile paralysis” also affected adults and such a victim, it was widely believed, was Mr. Franklin D. Roosevelt, a successful politician when it struck him in 1921 at age 39. He spent years in recuperation, and even afterward continued to struggle with the sequelae of severe lower extremity weakness, that he masked from the public when re-entering the political world as Governor of New York in 1928 and ascending to presidency in 1933. In retrospect, it is more likely that Guillain-Barre was the cause of his neuropathy. The polio story would intersect with the University of Michigan story two decades later. [Below: Photo: Two early-1950s March of Dimes “Fight Infantile Paralysis” posters designed by artist John Falter (of Falls City, Nebraska). (History Nebraska 10645-1197, 10645-4333)]

In the summer of 1953, many children throughout the northern hemisphere contracted polio, a seasonal fear of parents. Two children of a UM faculty member in the Surgery Department and practitioner at St. Joe’s were among those diagnosed. They were hospitalized for three weeks in the old “Contagious Hospital” during the presumed infectious period and then transferred, when afebrile, to a large ward of 32 beds in University Hospital (Old Main) on 10 West for the next five months of complete bed rest wearing knee-high boots, to prevent contractions, 24 hours a day.

One of the children, our colleague Skip Campbell, recalls watching Medical Sciences I Building being built from the ground up as he lay in bed. The “Sister Kenney Treatment” involved hot steaming under wool blankets twice daily. Both Campbell children recovered, although Skip’s sister had a life-long limp due to unilateral muscle atrophy. Skip recalled: “Quite a few kids in that place died, including a little girl in our room. Remarkably, I don’t remember a single nurse, doctor or my parents wearing mask!” [Personal recollection, Darrell Campbell, Jr., May 1, 2020.]

Sister Elizabeth Kenney (1880-1952) was a self-trained Australian nurse. After experience in WWI and with the 1918 influenza epidemic who in 1942 opened a clinic in Brisbane where she utilized heat packs and exercise among other regimens for polio. She brought her ideas to the US and settled in Minneapolis where the city gave her a house and she taught and practiced for 11 years. That work would lead into a new field variously called Rehabilitation Medicine, Physical Therapy, and Physiotherapy. [Below, Nurse Kenney, August 4, 1915 enroute to service in the Great War. Wikipedia, John Oxley Library, State Library of Queensland.] 



The Salk vaccine and enormous clinical trial (largely funded by FDR’s March of Dimes) coordinated by his professor Thomas Francis at the University of Michigan in 1954 largely eliminated the risk and fear of polio in North America. Salk used “killed virus” in his vaccine and despite safety testing, some batches from Cuter Laboratories contained live virus later linked to over 250 cases of iatrogenic polio. Greater government oversight of vaccine production was called for, but ultimately an oral vaccine from Albert Sabin’s team proved safer and gave more lasting immunity, although U.S. authorities were not initially interested in anything but the Salk series of injections and Sabin had to conduct his first large scale trial in the Soviet Union in 1959. [Below: Photo: Nebraska clinical trial of the Salk polio vaccine, May 1954. From KOLN/KGIN-TV, Lincoln and Grand Island. (History Nebraska RG809-51)]

Polio testing children, May, 1954.


Five.

Shimomura Crossing the Delaware, a provocative self-portrait of the artist Roger Shimomura, is prominently displayed at the National Portrait Gallery in Washington DC, – a wonderful place to visit when museums open to the public again.

At first glance Shimomura seems to turn history upside down, but with a little contemplation his work amplifies the idea of the American Dream. The artist fairly claims that America is his country too in 2010 as much as it was that of George Washington, who is more traditionally envisioned crossing the Delaware River on December 25, 1776. Shimomura’s large and striking painting, created nearly 70 years after Executive Order 9066, recapitulates the 1851 work of Emanuel Leutze at the Metropolitan Museum of Art (Washington Crossing the Delaware), but replaces Washington with Shimomura, the colonial troops with samurai warriors, and the geographical location with San Francisco Harbor and Angel Island, once a processing point for Asian immigrants.

In 1942, Shimomura, was not quite three years old when he and his family were forcibly relocated from their home in Seattle to an internment camp in Idaho. Franklin Roosevelt’s Executive Order 9066, signed two months after Pearl Harbor, caused this horrible trauma. That single presidential action designated military commanders to designate exclusion zones from which any American citizens or non-citizens could be excluded and relocated. Census data helped compile lists of such persons. Ultimately, 120,000 people, around two-thirds being U.S. citizens, were relocated to around 50 internment camps.

Ultimately, it is clear that the executive order and resulting program were based on “willful historical inaccuracies and intentional falsehoods,” according to a 1942 Naval Intelligence report that was suppressed by Roosevelt’s solicitor general Charles Fahey. The relocated people had posed no security threat, it was evident even at the time. Fear and ethnic bias left this terrible blemish on Roosevelt’s administration and the American narrative. 

The point here is that each of us creates their own origin story from their history as they know it – built on individual identities, beliefs, and aspirations. George Washington and Roger Shimomura had theirs, you and I have ours, and George Floyd had his. Each is as remarkably different as they are similar, sharing remarkable fundamentalities. John F. Kennedy may have said it best in his speech at The American University, Washington, D.C., June 10, 1963: “For in the final analysis, our most basic common link is that we all inhabit this small planet, we all breathe the same air, we all cherish our children’s future, and we are all mortal.”


Postscripts.

Another Shimomura. 

Osamu Shimomura (1928-2018) is a name that rings a bell for biological scientists. Not directly related to the American painter, Osamu was born near Kyoto he was a 17-year-old living in the Nagasaki area when the atomic bomb exploded 25 km away, blinding him for about 30 seconds and then drenching him with the black rain of the fallout. Against the odds he survived, was educated, and achieved great academic success, culminating in a Nobel Prize in chemistry in 2008 for his discovery of aequorin and green fluorescent protein. 

 

Ed Tank reminiscences.

Sherman Silber: “I am very sorry to hear of Ed Tank’s passing.  He taught me a lot from gender assignment in intersex cases to high diversion with pediatric hydronephrosis, which got me in deep trouble with some very opinionated and obstinate people.  He taught me a lot about adrenogenital and testicular feminization, and the bigger issue of the origin of gender identity and SEX preference.”  

Paul DeRidder: “I just read your latest “Matula Thoughts” and saw the article on Ed Tank.  In my senior year of medical school, 1971, I took a rotation in Urology.  Ed Tank was more or less my mentor.  I remember him well.  He was a determined surgeon, strong personality and great mentor.  I remember his suggestion that I review a text in pediatric urology, which I diligently went to the library to review many times.  He saw me in the library and was surprised that I was diligent enough to spent time reading the suggested text in my free time at the library. It was because of Ed, my feeling, that I was accepted to the Urology program as an intern, 1972.  When I completed my training, Ed had moved to Portland and as I was looking West to set up practice, I contacted Ed and asked if there were any openings in the Portland region.  HIs comment was “oh, no it is paradise here and we are saturated with Urologists.” He suggested I look elsewhere. Great guy!”


Thanks for reading Matula Thoughts, this July, 2020.
David A. Bloom

Back on the road to contagious hospitals

Matula Thoughts 1 May 2020
2430 words


Back on the road to contagious hospitals

“Reading gives us someplace to go when we have to stay where we are.”
Mason Cooley, American aphorist, 1927-2002.


[UH & UMMS Early spring 2020 on the road from old AA train station to main campus of Michigan Medicine.]

One.

Back on the road. May is usually a sweet spot in the calendar, but not so sweet around the world this year. Some random mistakes in the RNA sequences of a single common virus created a new version that has wrecked worldwide havoc on health, hospitals, and economies. Normally in May, memories and anticipations run strong, for it is a particularly sensual time of the year when colors, smells, tastes, sounds, seem to have especially bright notes after winter dormancy has lifted in the northern hemisphere. That sense of memory and anticipation is reflected in William Carlos Williams’s curious piece, Spring and All [By the road to the contagious hospital], written by the New Jersey physician and published in 1923. The title has long intrigued me and the content continues to puzzle me. Williams was a doctor in New Jersey, who wrote in his spare time. He was an excellent physician, my friend Joan Chiaviello Flanigan recalls from his care for her family when she was a child.

The odd free verse poem of Williams is deliberately mal-organized into 27 sections (identified by Roman enumeration I through XXVII, minus the missing number VII), with random prose interludes of commentary, “chapters,” and unidentified “footnotes” interspersed throughout it. An upside-down Chapter XIII follows a normally-oriented Chapter 19 in the unspecified introduction to the poem. Most verbal images precede spring and are neither attractive or cheering. Spring and All, both poem and its world, is very much upside down and disordered, until XXII and the Red Wheel Barrow that helps set things right. [Below: the confusing “Chapter XIII.”]

 

Little did we expect, just a year ago writing here about Williams, that we would actually be back on the road to contagious hospitals this May in 2020. Luckily, the Michigan Medicine field hospital at the athletic complex did not require deployment several weeks ago because social distancing and personal hygiene flattened our covid19 curve enough to preclude the new contagious hospital in Ann Arbor – at least for now. Given the widely disseminated knowledge of historians and scientists, it is incredible that we were surprised (again) by a terrible infectious pandemic.

Two.

Contagious diseases worried the University of Michigan Medical School in 1897 when it converted a small laundry shack behind the Homeopathic Hospital into a Contagious Ward for diphtheria, smallpox, and scarlet fever, diseases barely mentioned in medical schools today. In 1914 the city of Ann Arbor, still recalling a 1908 smallpox epidemic, gave the university $25,000 for a new Contagious Disease Hospital with 24-beds in an isolated area, well to the east of the larger hospital grouping. The civic contribution was as much a matter of self-protection than generous philanthropy, although the two attitudes are not unrelated, for philanthropy after all is a self-protective attribute of humanity at the species level. [Below: Michigan’s Contagious Hospital 100 years ago. Bentley Library.]

Williams wrote Spring and All [By the road to the contagious hospital] at an exuberant time for the University of Michigan and its Medical School. Urologist Hugh Cabot, recently appointed dean (in 1921), was building a great medical faculty and new hospital. Michigan’s  contagious hospital of that time is now long gone and the idea of contagious hospitals had all but disappeared in Ann Arbor and around the world, until this past winter. Some modern hospitals, such as our new Mott Children’s Hospital have been built for contingencies of terrible new epidemic possibilities such as SARS and Ebola, as well as resurgences of ancient ones like measles – perplexing and only understandable because of persistent human folly. Contagious hospitals revived in Wuhan and Manhattan this winter, although they seem to be more contagious dormitories rather than hospitals as we now think of them.

Three.

A May birthday. One birthday to recall this month is that of Dorothy Mary Crowfoot Hodgkin, born on 12 May 1910 in Cairo, Egypt. I first became interested in Hodgkin when I saw a painting of her at the National Portrait Museum in London, last winter during a visit for the wedding of the daughter of my good friends from our training years in London, Robert and Anita Morgan. The painting was prominently displayed and instantly attractive, but a mistake in the label next to it caught my attention.

Dorothy was the oldest of three daughters of John Winter Crowfoot, a civil servant in the Ministry of Education, and his wife Grace Mary Hood. Living and working in Egypt for many years, the family returned to their native England each summer in the hot months and during one of those summers WWI began. In that August of 1914 the parents left their girls with paternal grandparents near Worthing to return to Egypt, where father could continue work.

After the war, the reunited Crowfoots relocated to Sudan where Mr. Crowfoot was put in charge of national education and archeology, until 1926. The girls attended local schools in Sudan and Dorothy became fascinated by archeology and the mosaic tiles in Byzantine-era churches. She also developed an interest in chemistry and her mother, a botanist, gave her a book on x-ray crystallography for her 16th birthday. Dorothy combined her interests by drawing pictures of mosaic patterns and doing chemical analyses of the tile cubes, called tessera. At age 18 she returned to England to study chemistry at Somerville College, Oxford, and received first-class honors in 1932, proceeding then to Newnham College, Cambridge for Ph.D. studies.

Dorothy worked with John Desmond Bernal on applications of x-ray crystallography to protein analytics and their work on the structure of pepsin turned out to be the first biological crystallographic analysis. Dorothy obtained her Ph.D. in 1937 for work on sterol structure and she held a post as Oxford’s first fellow and tutor in chemistry until 1977. In 1964 Hodgkin won the Nobel Prize in Chemistry. [Below: Hodgkin’s model of penicillin. Science Museum London, Science and Society Picture Library.]

Molecular model of Penicillin by Dorothy Hodgkin, c.1945.

One of her students, a young woman named Margaret Roberts at Oxford from 1943 through 1947, wrote a dissertation on the x-ray diffraction of the antibiotic gramicidin that led to a good job in industrial chemistry but Roberts turned to politics around 1950, married Dennis Thatcher in 1951, and qualified as a barrister in 1953. In 1959, then Margaret Thatcher, she was elected member of Parliament, rising to Prime Minister in 1979. In her office at 10 Downing Street Thatcher displayed a portrait of her former teacher. Hodgkin, however, was a life-long supporter of the Labour Party. [Below: Hodgkin legend with corrected name of artist. National Portrait Gallery London, December, 2019.]


The mistake that caught my eye at the National Portrait Gallery was in the adjacent description of painting and artist, Maggi Hambling, where her first name was written “Maggie,” but someone (I’d imagined it might have been the offended artist herself) crossed out the final “e” with what seemed to be a pencil. No matter, the museum is now closed down for a lengthy renovation and time will likely heal this minor error.

Four.

Among the many innovative changes Ganesh Palapattu has brought to the Department of Urology is the broadening of the weekly grand rounds conferences to periodic wider learning experiences that extend beyond world of urology, that he calls “Teach us something.” A session of this nature in late February featured Professor James Kibbie, Chair of the University of Michigan Organ Department who taught us something in the School of Public Health (SPH) where one of the 16 pipe organs of the University of Michigan temporarily resides. In late February Professor Kibbie spoke on “Bach and the Organ,” and treated our faculty and residents to three beautiful pieces (played on the James Walgreen Létourneau Organ on loan to the SPH) from the 270 surviving organ compositions of Bach. [Above: Professor Kibbie at urology grand rounds.]

Kibbie has been collaborating with computational faculty to understand the science behind Bach’s music and a recent grant from Barbara Sloat allowed him to record all of the Bach organ works, all 270 pieces, performing them on instruments of Bach’s era located mainly in Germany. These works are available to the public through the University of Michigan. [From Prof. Kibbie: “If you want to add the URL for the university’s website with the free downloads of my Bach recordings, it’s http://www.blockmrecords.org/bach.”%5D


[Above: Kibbie, Vesna Ivanĉić, Sam Kaffenberger.]
The pipe organ, complex and large, manipulates forced air through many ingenious pipes. Mistakes are inevitable in all spontaneous performances and Professor Kibbie explained how organ recitals are particularly susceptible, having three keyboards, multiple stops, layers of foot pedals, hundreds or more pipes, and up to 100,000 parts. Paired with the human factor, pipe organs offer countless opportunities for performance variations and transcription errors. Of course, Professor Kibbie’s ear can register musical mistakes that fly by most of us with untrained attention.

Everyone makes mistakes from the moment they arise in the morning, whether squeezing out too much or too little toothpaste, rolling through a stop sign on the way to work, or parking too close to an adjacent car – the possibilities are myriad although most are inconsequential. Error is something we understand in clinical work. Medical mistakes may be transcribing errors when writing (now, typing) patient stories, missing veins on blood draws, or making erroneous clinical decisions. To err is human, to err consequentially is unfortunate.

Algorithms promise perfection, if we are naïve enough to forget that they are written by humans. Whereas a piano played spontaneously offers novel idiosyncratic momentary interpretations, innovations, or mistakes that combine to make each performance unique – and mistakes are nearly inevitable –  a programmed piano (player piano) is free of performance interpretation and variation. The standardization (assumed to be error-free, but any algorithm is only as good as its author) brings freedom from the anxiety and art of human performance.



Five.

A scarlet tanager showed up in our old neighborhood last May around this time. My neighbor, Mike Hommel, called to alert me one Friday afternoon when I was indoors on the computer working on the Urology Department history. Mike is a great naturalist who can spot morels on the ground and birds in the trees better than anyone I know and that day, specifically 10 May 2019, he spotted this little fellow, tired and resting after a long flight from somewhere in the south. The splash of color is amazing and has served its evolutionary purposes well. This little guy was not too concerned by our attention as it shifted trees periodically and hopped to the ground to feed from time-to-time.

Had William Carlos Williams spotted a scarlet tanager on his road to the contagious hospital, the poem would probably have been much different. (Such are the contingencies of life.) Piranga olivacea used to be categorized in the bird family Thraupidae within the Passeriformes family (the perching birds with one backward and three forward toes) but DNA studies have reclassified them to the cardinal family (Cardinalidae). When I was younger the Linnaean binomial classification held little interest for me, but my perspective has changed. I looked for the tanager the next day, but he had moved on. A number of deer, however inspected me carefully. They used to drive us crazy, eating everything we planted, and either we would shoo them away or our dog, Molly, would give chase. By May, 2019, Molly’s arthritis had erased her interest defending the property and at that point the property seemed to belong more to the deer than to Molly or us, which was just as well for we had sold the house to downsize in downtown Ann Arbor.

Other hopeful signs of spring popped up last month, oblivious of the prevailing RNA threat to humans. [Above and below: early April 2020, Ann Arbor Water Hill area.]

[Above: pond in West Park. Below: new normal – outdoor picnic tables at Zingerman’s replaced by spaced waiting areas for take-out orders.]

 


Postscript.

Disruption. Is clinical medicine a performance art, as aspired to by professionals since Hippocratic times, or is it becoming an algorithmic practice? Professor Kibbie provoked this question. The doctor-patient relationship has been disrupted by the “encounter” framed by the electronic health record (EHR) format, that is the ubiquitous EHR-directed patient “encounters” have replaced the narratives my generation was taught to elicit. We used to initiate evaluation of patients using the so-called SOAP notes (subjective, objective, assessment, and plan) that align with the medical gaze – Sherlockian/Oslerian scrutiny by a trained observer. 

A “chief complaint” was a story that could be boiled down to a phrase, but narrative demanded more and gave the chief complaint context. Shoulder pain could be a malignant metastasis or a rotator cuff injury and it was important to know if the injury was life-style related, due to occupation, or traumatic; the story behind the pain, its comorbidities and social determinants, are no less relevant than the pain itself. Abstraction of a patient’s story to a drop-down phrase or an ICD-10 numeric diagnostic code is a poor substitute for conversation, medical gaze, and narrative. We should resist this terrible trend as best we can and create EHRs that support narrative inquiry and medical gaze rather than commoditize encounters.

One hundred years ago, Hugh Cabot got off the train from Boston at the old Ann Arbor station (shown at the top) and initiated the first century of Michigan Urology, not knowing that he would have little more than a decade to do it. Medical care had its disrupters back then, new technology, burgeoning subspecialties, and novel models of practice. Some tension existed between the old and the new approach to disease. Classical Oslerian ideas are routed in the bedside medical gaze and dialogue with the patient to understand and explain the problem. The new scientific approach sought to understand disease based on facts derived in research laboratories, other sources of verifiable data, or from the patient as a virtual laboratory. Clever clinicians recognize it is not a matter of one or the other, patients deserve both approaches. Brutal realities of a post-covid19 world will favor the curt, transactional, commodity aspects of health care. Role models in fiction and fact such as Sherlock Holmes and William Osler, and new analyses such as The Good Doctor – Why Medical Uncertainty Matters, a book out soon by Kenneth Brigham and Michael Johns, help navigate this new era of disruption.

[Below: sign of spring, late April, near Barton Pond.]



Thanks for reading Matula Thoughts of May, 2020.
David A. Bloom, University of Michigan Department of Urology

April, perhaps the cruelest month

WN/MT 3 April 2020
2356 words

This April, perhaps the cruelest month



One.

April, was the original title of this painting by American impressionist Frederick Childe Hassam, a century ago, in 1920. It was an optimistic time when the world was rebounding from years when the thin veneer of civilization seemed to be wearing away with war and influenza. The pendulum of events changed for the better and, in Ann Arbor, Hugh Cabot started up a century of modern urology at the University of Michigan.

It is a mystery what drove Hassam, just then, to go back to his very beginnings with this work. Maybe the emergence of the world from the edge of catastrophe just then was a factor. He renamed his painting, Green Gown, the woman in green being Rosa Delia Hawthorne, Hassam’s mother, depicted in an April a half century earlier when three months pregnant with Frederick (born October 17, 1859 in the family home in Dorchester, Massachusetts). [Above: April, Courtesy, Gibbes Art Museum.] The gorgeous composition shows Hassam’s imagination of his mother at 27 years of age, reclining pensively on a settee, as if considering her next 6 months of confinement or the joys and trials of parenthood. A daffodil arrangement in the right foreground reinforces the time of year in the original title. Yet it was an odd concept for a painting, with the artist picturing his mother in the first trimester of pregnancy with him, at his actual beginning. This was a curious contrast to Whistler’s famous consideration of his own much older mother a half century earlier.

Hassam’s painting is a suitable introduction to April, the beginning of spring in the northern hemisphere, when showers anticipate May flowers, as the saying goes. Another painting by Hassam, The Avenue in the Rain (in the White House Collection) depicts Fifth Avenue in NY around the time of WWI and perhaps during some April showers. This was one of 30 paintings in Hassam’s Flag Series.



Hassam purchased a home in 1919 in East Hampton where he most likely painted April the following year and would live another 15 years, dying in East Hampton at a respectable 75. The country was in a patriotic mood in April, 1920, with the Great War and recent influenza epidemic no longer existential threats, but the national optimism eclipsed any prudent attention and resources to prepare for the next iterations of existential threats. This April, normally a time for beginnings, existential threats are back at civilization’s door. [Above: The Avenue in the Rain. Hassam, 1917. White House Collection, since the Kennedy Administration. Below: Oval Office 2009, photo by Pete Souza with the president and the picture on the wall.]





Two.

A century is a convenient milestone, although most humans fall short of this in their life spans. The modern average of “three score and ten” or so, however, is ample time to leave something behind, if one is fortunate, in good works, successors, and kindness. Octogenarians, septuagenarians, and centenarians are rarities, the products of good genes and lucky circumstances. The U.S has 80,000 centenarians, the U.N. estimates 343,000 worldwide in 2012 and projects 3.2 million by 2050.

A century is an extreme stretch for a single human, few make it that long, but human collectives – nations, organizations, corporations, and other teams – are not limited biologically and for them a century is a useful ruler to measure accomplishments and create historical narratives. So, consider medical practice and urology in April 1920, in particular, when the grim experiences of war and influenza were fading from memory, although some lessons learned were working their way into civilian health care. The growing scientific knowledge base of medicine and its burgeoning subspecialties by 1920 had rendered medical school alone insufficient training for the new generation of medical practitioners; internships and residency programs were producing a new world of graduate medical education that became the career-defining element of medical training.

This centennial year of urology at the University of Michigan is an opportunity to understand our organizational corporate past and some of the many stories relevant to Michigan Urology. Additionally, the centennial is a chance to personally reconcile with our roots in healthcare and at the University.

With the present world turned upside down by Covid19, the AUA in Washington, DC and Sunday Nesbit reception are cancelled, but we look forward to the autumn and September 24-26 with the Nesbit alumni reunion here in Ann Arbor, featuring guest speaker alumni Carol Bennett, Barry Kogan, Ananias Diokno, Carl Smith, Curtis Nickel, Mitch Albom, and Sherman Silber, among others. The first of our two books on Michigan Urology will soon be available (and also online via Michigan Publishing), this being Urology at Michigan – The Origin Story, tracing the development of genitourinary surgery, the University of Michigan, its Medical School, and the introduction of modern urology to Ann Arbor by Hugh Cabot. Book two will cover the first hundred years of urology at Michigan, year by year, expanding on the Konnak and Pardanani text that Jim Montie commissioned 20 years ago. We hope to finish this in the next year.

This April 2020 it’s natural to pause for a moment and consider what urology practice and education were like 100 years ago. Cystoscopy, a new skill of the late 19th century, required special instruments and novel expertise that defined urology and fueled its early creative burst. A new breed of surgeons picked up cystoscopy, improved the technology, gained insight into genitourinary dysfunction, and created miracles of minimally-invasive therapy. Nonoperative and open solutions to urinary problems expanded urology, after it was so-named in 1902. Urology came together as an open organization in 1910, created rational training programs for young physicians, and formed its own journal in 1917. Little of this progress translated to the battlefields of WWI, but the civilian progress accelerated after its conclusion, although barely in time to be applied in the next war.


Three. 

 

In April, 1920, the Cabots were adjusting to their new lives in Ann Arbor. Hugh was busy as chair of the Surgery Department and the sole urologist at the University of Michigan. Cabot’s two competitors in Ann Arbor, still calling themselves genitourinary surgeons, had left the university to practice a few blocks away at St. Joseph’s Mercy Hospital and neither they nor Cabot had any interest in collegial relationship. The University Hospital complex was physically constrained and outdated, pale in comparison to the facilities Cabot left behind in Boston, but a quantum leap from the 2,500-bed hospital he had commanded in France on the Western Front of the Great War.

The Cabot family was living temporarily in the President’s House, having cajoled the Regents into its use pending the anticipated summer arrival of incoming President Burton. Anxiety was growing within the university administration as it tried to coordinate renovations demanded by the Burtons and uncertainty over the Cabot’s plans. At work, Cabot had to manage the teaching and clinical responsibilities of his small Surgery Department, deploying the full-time compensation model. To grow his small and inbred Surgery Department Cabot leveraged his military connections to bring two essential additions to Michigan that year, Frederick Coller and John Alexander.


Four.

Just about halfway between the start of the Michigan Urology centenary and now, I began my era of training. It was 1971 and urology was at a watershed. It sat between an era of board-certified urologists with life-long certification working in individual or small practices and the present era of urologists with contingent re-certification working in large practices or multispecialty health systems. In 1971 fiberoptic cystoscopy had only recently replaced first generation cystoscopes, illuminated by distal mignon lamps of Edisonian technology; transurethral surgery was one of surgery’s rare minimally-invasive operative procedures; major open reconstructive urologic procedures were available at only a few centers; the intravenous pyelogram and retrograde injection studies were the main imaging modalities (ultrasonography was in its primitive stages); and training programs were mostly small and weakly standardized. That year, Jack Lapides Section Head of Michigan Urology from 1968 through 1983, introduced his strongly disparaged idea of clean intermittent catheterization.

Meaningful visual cystoscopic acuity for old-time urologists required much skill, art, and experience. For learners, peeping over the shoulder of  cystoscopists (whenever they decided to let learners have a look), the opportunity was fleeting. This scenario earned Jack Lapides his covert nickname, Black Jack: for he was known to temporarily disconnect the light cord (by stealth of hand) before letting the learner look through the scope and asking what they saw. [Below, Jack Lapides photo by DAB.]



Lapides had been a loyal and productive lieutenant to Reed Nesbit for some 20 years. When Reed was aiming toward retirement in 1967, Jack no doubt felt inclined to take over the leadership of the small section. The two urologists seemed to have gotten along well professionally, although there was no doubt as to who was in charge and it didn’t seem that a strong friendship existed outside the workplace. Lapides had been running his own separate and independent residency program at Wayne County Hospital, graduating a single chief each year whereas at this point the UM program was finishing 2-3 per year.

Karl Montague (UMMS 1968), visited by us last autumn at the Cleveland Clinic, recalled his experience as a junior medical student rotating on urology. Karl had been focused on a career in cardiology, primed in that direction by an NIH fellowship in Basel, Switzerland. Urology at the University of Michigan was then a mandatory clinical rotation and Montague recalls some of Lapides’ pedagogical antics (at the VA):

“Dr. Lapides was demonstrating cystoscopy to a group of us medical students in our third year. Of course, this was before the time of video teaching and the learner had to peer over the shoulder of the teacher who had positioned the scope over a landmark view of anatomy or pathology, while the patient was under anesthesia as happened to be the case that day. So Dr. Lapides had the first student in turn to look in the scope and asked: ‘Do you see the verumontanum?’ The student, after a few awkward moments said ‘Yes’ and Lapides checked the position and asked the next student, who again agreed. When it was my turn, I looked and looked and finally said ‘No.’ It turned out that the Professor was holding the scope in the middle of the full bladder, nowhere near the veru. He seemed to like me after that day and later in the rotation asked my career plans. I told him it was cardiology. He said: ‘Think about urology, and if it interests you, come back and talk to me.'”

Montague did give some thought to urology and that changed his career arc and life. It was a clever and kind approach on the part of Lapides, kinder than the anecdotal “Black Jack” stories. [Below, Montague in his office at Cleveland Clinic, autumn 2019.]




Five.

Kindness & Kurt Vonnegut Jr. (November 22, 1922 – April 11, 2007). The Vonnegut books I read in college, medical school, and during residency offered great escape from study with humor, satire, and surreptitious insight into the thing we call, the human condition. More than appreciated at the time, Vonnegut expanded my sensitivities to the comorbidities of life, environmental deterioration, and the quality of kindness. Cat’s Cradle (1963), iconic book, offered very short chapters that fit my short extracurricular attention span. [Above: “Two Young Women Seated playing cat’s cradle.” Suzuki Harunobu, ca. 1765. Wikipedia.] Slaughterhouse-Five (1969, film 1972) didn’t mean so much to me then, but years later hearing a beautifully performed audiobook, I felt its powerful impact, reflecting Vonnegut’s lived experiences as a prisoner of war in the Allied firebombing of Dresden. Even though I served in a peacetime Army for four years after my residency training, I had gained enough maturity, experience, and knowledge to appreciate that mind-bending book. 

Vonnegut told stories of contrived odd characters and places. While exaggerated and even preposterous, he resonated with the best and worst of human attributes. God Bless You Mr. Rosewater (1965) only came recently to me, as I was tracking a quote that reflects Vonnegut’s dark humor and the hope that underlies his satire. The quote came from an anticipated baptismal greeting:

“Hello babies.

Welcome to Earth.

It’s hot in the summer & cold in the winter.

It’s round & wet & crowded.

On the outside, babies, you’ve got 100 years here.

There’s only one rule that I know of, babies –

God damn it, you’ve got to be kind.”

T.S. Eliot once called April “the cruelest month” so it seems fitting to conclude now with thoughts of kindness, a trait that seems to come naturally to some people, but most of us have to work at it, balancing it against our selfish particularities. Kindness is a very human trait, the very basis of civilization, although many other creatures evidence kindness in numerous ways. Kindness is, no doubt, tied into mirror neurons, oxytocin, and other incredible biologic inventions that we are dimly aware of at best. Motherhood is the ultimate expression of kindness, perhaps that was on Hassam’s mind to some extent in April, 1920.

 

Postscript.

With few centurions living today, only historians can tell us much about what daily life was like during the big influenza epidemic of 1918-1920 that ended around the time Michigan Urology’s first century began. And, of course, one hundred years from today, will many people fully understand the anxieties, terrors, and tragedies of the present moment in time.

Kindness is always at risk in the busy workplaces of healthcare, and this will be especially tested in this current pandemic threat (Coronavirus 19), that has taken civilization by surprise. We are too often surprised by infectious diseases, whether cyclic or novel and while our immune systems may be surprised, our brains have no excuse. Here is an amateur historian’s list of the last big pandemics:

HIV/AIDS rising from 1976 to 1981 and peaking 2005-2012, killing 36 million

Influenza H3N2 1968 killing 1 million

Influenza H2N2 1956-58 killing 2 million

Influenza H1N1 1918-1920 killing 20-50 million

Sixth cholera pandemic 1910-1911, killing somewhat under 1 million, estimated.

Influenza H3N8 1889 – 1890 killing 1 million

Third cholera pandemic 1852-1860 killing 1 million

Black Death (bubonic) 1346-1353 killing upwards of 200 million

The Plague of Justinian (bubonic) 541-543 killing up to 25 million

[Above: Red Cross volunteers assembling gauze face masks at Camp Devens, MA, 1918.] 

Thanks for reading Matula Thoughts this April, 2020. It will be a rough month.

David A. Bloom
Department of Urology
University of Michigan

March thoughts, idle and otherwise

WN/MT 6 March 2020

March thoughts, idle & otherwise
2102 words

 

One.

Be cautious in mid-March, the spirit of Julius Caesar warns. It’s not idle advice, for Caesar must have had a tin ear to the political dissent building up around him, or else the mantle of authority made him feel unassailable until he was terminally disabused of that conceit on the Ides of March 15 in 44 BCE. A coin issued by Brutus two years after Caesar’s assassination (shown above) celebrated the would-be king’s downfall. Before the Ides of March became notorious, that day in the Roman calendar was reserved for religious observances and settling of debts. It so happens that the big settling of debts in American society two millennia later has been displaced a full month in the calendar to April 15 for taxpayers like me and businesses not clever enough to find the loopholes. [Above: Eid Mar coin reverse, the tail side. Below: Wikipedia, The Tusculum likeness of Julius Caesar, photographer Gautier Poupeau.]

No one wants to be overly superstitious, but it is wise to venture forth with a measure of caution not only on the Ides of March but every day, monitoring your physical and political environments, on the lookout for “hungry looking” Brutuses and watching for reckless scooters, distracted walkers or drivers, rising seas, hurricanes, fires, blizzards, tornados, or merely uncovered sneezes and coughs. (By the way, why is it socially accepted that we expect ourselves or others to cover coughs or sneezes only when “feeling sick” with a fever? Why doesn’t every adult carry a handkerchief or tissue to cover every cough or sneeze – especially in these coronavirus times ?!)

Ancient Roman days were counted differently than they are now, with three named points each month: the Nones in the early month, the Ides in mid-month, and the Kalends on the first of the next month. Assassination perp Brutus issued the coin in the fall of 42 BC, and that Eid Mar denarius shows a “freedom cap” positioned between two daggers.

The denarius was the standard coin in the Roman Empire from 267 BC until replaced by the antoninianus in the mid-3rd century AD, the coin of Galen’s day. The silver in the coin was initially worth about a day’s wages for skilled laborers at that time in Rome, today that equivalent amount of silver is less than $4. Emperor Nero, about 100 years after Caesar’s assassination, began to debase the coin, substituting cheap metal for the silver, until hardly any silver was left by the end of its use. The Eid Mar value, however, has greatly appreciated – a single coin recently fetching 325,000 Swiss francs ($332,583) at auction on Oct. 6, 2016.

[Above: Eid Mar coin obverse – the head side with Brutus. Below: Silver content debasement by year of Roman Empire denarius and its successors, 11 BC to 250 AD. Wikipedia: Data from Walker, D.R. (1976-78), The Metrology of the Roman Silver Coinage. Parts I to III. Nicolas Perrault III.]

 

Two.

Coffee Houses. My youngest daughter and her husband, both academics, do much of their work in coffee houses, as do many of their generation. Before computers and the internet, coffee houses were places to meet and converse. Now, it’s more common to see people with ear buds in place and eyes focused on their work on laptops and (annoyingly) on phones.

The coffee house of Edward Lloyd on Tower Street in London around 1686 was the room where it happened that marine insurance blossomed and grew into an essential component of modern business and life. Insurance was a necessary ingredient in the emergence of the limited liability company, that is, the modern corporation underpinning modern capitalism. Coffee houses have been important social hubs for over 300 years in Western Society and the tea customs in Asia have been around much longer. The Cosy Corner Tea Shop of Mrs. Hugh Cabot opened in Ann Arbor 1923 and became a small part of the Michigan Urology story, with its own backstory of how social changes and the Great War changed expectations for one faculty wife. Coffee and tea houses today serve as primary places to plug into earpieces and computers so as to disconnect from people and immediate scenes around you and leap into distant people, scenes, and your own imagination. Oddly, socialization and social media are not very compatible.

The Coffee House, in the winter of 1905/1906, a painting by Alson Skinner Clark (1876-1949), shows the State Street Bridge amidst smoke, fog, and early “skyscrapers” over an icy river. You can barely identify the actual coffee house. [Above: Institute of Art, Chicago.] The title suggests Clark either painted the scene in real time (en plein air) or recalled it from his time in the neighborhood, although he was also an accomplished photographer and may have used that medium to help fashion the painting. The view is not vastly different a century later, the high rises are higher and more numerous, the horsepower of street transportation has increased (without much increase in the transit time per mile), and the price of a cup of coffee has gone up. That same neighborhood these days contains at least several Starbucks and other coffee houses. [Below: State Street Bridge in early spring 2019 during AUA national meeting.]

 

Three.

Coffee beans. I can’t spend too long in coffee houses without recalling the great Danish story teller Karen Blixen, known more widely by her pen name, Isak Dinesen. Out of Africa in 1937, described her years in British East Africa (modern-day Kenya) between December 1913 and August 1931. She initially tried to raise cattle, but switched to growing coffee beans although that, too, proved difficult. The soil and high elevation were not perfectly conductive, East African conflicts in First World War interfered with supplies and equipment, and ultimately the Great Depression made the business untenable. Having run through her family’s money, Blixen returned to her family home in Denmark to write. Her work there proved far more successful and enduring than the Karen Coffee Company and she became a world celebrity, dying in 1962 at age 77. Orson Wells planned a film anthology of her work, but never completed it, producing only The Immortal Story (1968). Babette’s Feast (1987) became an extraordinary black and white film of a somber isolated Scandinavian village and Out of Africa (1985) was gorgeously filmed in color featuring Meryl Streep and Robert Redford. Last autumn, while at the terrific CopMich meeting organized by Dana Ohl and Jens Sønksen, I spent an afternoon at the Blixen family home in Rungstedlund. [Above: Photo by Sophus Juncker-Jensen (1859-1940) taken in 1913 shortly before Blixen’s departure for Africa. Below: Karen Blixen’s home, Rungstedlund, 2019.]

The Isak Dinesen quote that comes to mind after an hour or so in a coffee house is from Seven Gothic Tales:

“What is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.”

Unpleasantly, the name Karen, like many other terms on social media, has become a derogatory meme. [Below: Wikipedia: Baroness Karen von Blixen-Finecke at Kastrup Airport CPH, Copenhagen 1957-11-02.]

 

Four.

A book on urine. In 1917, when Karen Blixen was cultivating coffee by day and telling stories to her friends at night and Michigan Urology founder Hugh Cabot was serving on the Western Front for the British Expeditionary Forces during WWI, Arthur Robertson Cushny, former University of Michigan professor from 1893 to 1905, was working at University College London when he published Secretion of the Urine, a book explaining the machinery and infinite artfulness of urine production. [Above: Cushny, Wellcome Museum. Below: title page.]

Cushny took uroscopy to a new level of detail. Uroscopy began in ancient times with basic sensory evaluation of urine (color, odor, taste, etc.). Medieval uromancy offered speculative linkage of urine findings to diagnosis, and microscopic evaluation later opened new levels of visual detail. Chemical and microbial analysis, using 19th century tools and technology, provided meaningful therapeutic opportunities, but Cushny’s book of 1917, Secretion of the Urine, explained how urine was formed in health and disease, by filtration at the glomerulus and reabsorption/secretion along the renal tubules.

Arthur Cushny (1866-1926) had come to the Medical School in Ann Arbor to replace John Jacob Abel, a UM graduate from 1883 who had returned to Ann Arbor in 1891 to teach, pursue research, and create the world’s first department of pharmacology. Abel transformed the formal and ancient lectures on materia medica and toxicology into pharmacology instruction with demonstrations applicable to clinical practice of his time. Johns Hopkins lured him away in 1893, but that opened the door for Cushny to replace him as chair. Dean Victor Vaughan found Cushny in Berne, investigating the problem of death from chloroform anesthesia and developing methods of titrating the delivery. Cushny was an effective teacher and a productive researcher in Ann Arbor, but returned to Europe for an attractive job as chair of pharmacology at University College London in 1905 and in 1918 returned to his native Scotland as chair in Edinburgh, where he died in 1926. Secretion of Urine was a major contribution to physiology and urology. [Cushny AR. The Secretion of the Urine. London, Longmans, Green, 1917.]

 

Five.

You are what you eat, like most aphorisms, contains truth and hyperbole. It extends easily to other bodily inputs such as you are what you drink. [Above: The Cook, Guiseppe Arcimboldo 1570. National Museum, Sweden.] Last month’s suggestion, that you are what you read, regarding on The Crisis periodical, fortifies a parallel claim for mental nutrition, which came to mind again in another magazine that compels interest, The Economist. A recent piece in the recurring essay entitled “Johnson” (after Samuel Johnson, of dictionary fame), combined the recent custom of selecting “words of the year” and the phenomenon of adverse climate change. “Johnson” offered a number of candidates for word of the year, noting that according to the Dutch dictionary Van Dale, Dutch-speaking Belgiums voted for winkelhieren, a term for “buying locally,” as the 2019 word of the year. [Economist Jan 4, 2020, p. 62.]

Ann Arbor offers excellent examples for buying locally including Zingerman’s and Kerrytown markets for food and stuff, Literati for books, or Camera Mall for photographic things. Amazon is convenient, luring, and addictive but it robs from local communities (livelihoods and taxes). Plus, given the packaging and reported 30% return rate, that particular limited liability corporation accelerates planetary degradation. Perhaps a community becomes what it buys. If people buy mainly from Amazon, they will be an Amazon community as local businesses recede like the glaciers – not such an attractive possibility.

 

Postscript x 2: peas and war.

Gastronomic identity. In 1826 Anthelme Brillat-Savarin wrote, in Physiologie du Gout, ou Méditations de Gastronomie Transcendante: “Dis-moi ce que tu manges, je te dirai que tu es.” [Tell me what you eat and I will tell you what you are]. In 1940, Victor Lindlahr, nutritionist and enthusiast of the so-called catabolic diet, wrote a book You are what you eat: how to win and keep health with diet. In strict chemical and physiologic terms, it’s hard to deny that fact, although it’s nice to believe the human sum is actually greater than the sum of its nutritional parts, as the Italian painter Guiseppe Arcimboldo (1527-1593) hinted in his arresting works, such as Vertumnus. [Above: Emperor Rudolph II as Vertumnus, Roman god of seasons. c. 1590, Guiseppe Arcimboldo. Skokloster Castle, Sweden.]

The Battle of Columbus. Just around this time of year, in 1916 (March 9), Francisco “Pancho” Villa’s División del Norte raided the small border town of Columbus, NM and retreated back to Mexico. United States President Woodrow Wilson, while holding the U.S. back from the Great War in Europe (that Hugh Cabot entered as a volunteer with the British Expeditionary Forces) eagerly sent 4,800 U.S. troops led by General John Pershing over the U.S./Mexican border to capture Villa. [Above: Unmindful of the Ides, U.S. troops crossed into Mexico in March 1916 in pursuit of Pancho Villa. Photo courtesy U.S. Army Military History Institute.] The 9-month punitive incursion south of the border failed to capture Villa, but it did recruit University of Michigan Ph.D. Paul de Kruif, who joined as a private. The campaign ended in January 1917, without achieving its objective. Pershing claimed the effort a success, even though it seemed that the U.S. soldiers were the main parties punished. de Kruif went on to join the WWI effort after the U.S. officially entered the conflict, serving in the Sanitary Corps as a lieutenant and then captain before returning to Michigan for a short time. His next job was at the Rockefeller Institute until he was fired, rendering him the freedom to become a medical journalist and collaborator in 1926 with Sinclair Lewis in Arrowsmith.

 

Thanks for looking at this month’s communication from the University of Michigan Department of Urology. What’s New is the email version and matulathoughts.org is the web-based version.

David A. Bloom

November one

DAB Matula Thoughts November 1, 2019

One hundred years of urology
2615 words

One.

The origin of urology at the University of Michigan centers around its first three urologists Hugh Cabot, Charles Huggins, and Reed Nesbit, each having enormous impact in their individual ways. Cabot’s impact was academic, clinical, and organizational. Huggins came to Michigan for what was then called “postgraduate training” under Cabot and was inspired to a career in urology that took him to the University of Chicago as chief of urology and eventually to a Nobel Prize. Nesbit, roommate of Huggins as trainees, became Cabot’s successor and a noteworthy urologist, whose clinical innovation, organization leadership, and education of future leaders of his century, had few equals.

The story of genitourinary surgery, of course, actually began much earlier, with pre-Hippocratic roots and slow evolution until the second half of the 19th century when health sciences, modern technology, and medical subspecialties emerged and revolutionized medical care. The University of Michigan story is entwined with those changes, as one of the earliest public universities and in 1869 it was the first university to own and operate a teaching hospital. By the early 20th century the University of Michigan Medical School was noteworthy among its peers in teaching and research, but lagged behind in the clinical arena, a fact that some viewed as due to its small-town location. After the 1902 neologism by Ramon Guiteras the term ii replaced that of genitourinary surgery, although not until many years later in Ann Arbor.

Exactly one hundred years ago, on November 1, 1919, the University of Michigan Medical School, although still stuck in educational and clinical paradigms of the previous century, was on the precipice of major change that would launch it into the major leagues of 20th century academic medicine. Dean Victor Vaughan, an immeasurable influence since his arrival in 1874 as one of Michigan’s first two Ph.D. candidates, had been distracted by duties in Washington during WWI and was reeling from the death of one of his sons who had been about to return home from his service in Europe on the Western Front. Vaughan had other national leadership responsibilities on his plate in addition to the war effort and his inattention to Michigan had left the Medical School without chairs for its two main departments – internal medicine and surgery. In Boston Hugh Cabot had recently returned home from 2.5 years of service overseas to find his private surgical and urologic practice “evaporated.” He discovered the Ann Arbor opportunity for a fulltime salaried job as chair of surgery and jumped at it. Beginning work on October 12, 1919, he initially stayed at the Michigan Union, but soon convinced the regents to allow him with his wife and four children to live in the unoccupied University’s President House until a new president was in place.

Cabot was a necessary change agent for the Medical School. He was a top-of-the-line international urologic celebrity even before his 1918 textbook Modern Urology. It is telling that his predecessors in genitourinary teaching and practice at Michigan, interim surgery chair Cyrenus Darling and clinical professor Ira Dean Loree, had been holding on to the older name for the field. Cabot was a self-declared urologist. A prolific speaker and writer, he was assiduous in connecting with new ideas, other specialties, and novel technologies. During the war he became a skillful administrator, ultimately rising to Commanding Officer (CO) of a British Expeditionary Force (BEF) hospital with over 2,000 beds near the front. While he would bring leadership and modernity to Ann Arbor, his brusque style had already created detractors on the national scene, as evident in files at the Bentley Library where a letter to Victor Vaughan from Bostonian Dr. Frederick Shattuck on September 30, 1919 commented:

“Dear Vaughan:
I am greatly interested in your capture of Hugh Cabot for whom I have high regard and much affection, not so much because he is a first cousin of my wife, though very much younger, as for himself and what he is. His departure will be a loss to me, personally, and I think a loss to this community; but the more I reflect on the matter the more I feel that he can render greater service, and thus derive greater satisfaction from life by accepting your offer. Like other strong, positive men, he has made enemies, but I think his capacity to deal with men developed markedly during his service as C.O. of Base Hospital No. 22, B.E.F. There were difficulties connected with that practice which do not appear upon the surface, and it is my belief that, taking all things into consideration, he handled the job extremely well…”

Shattuck concluded the note offering condolence to Vaughan on the recent loss of a son in Europe, referring to the actual moment Vaughan got the terrible news just about as he was to preside over a session of the AMA at its Atlantic City meeting that summer. Cabot also must have been at that meeting, according to the correspondence, and it is likely that it was when and where he first learned of the Ann Arbor job, perhaps directly from Vaughan (letter below).

 

Two.

The first century of urology in Ann Arbor: October 1919 to October 2020. Michigan Urology now entertains a year-long celebration of its centennial. Cabot introduced modern urology to the University of Michigan when he arrived on October 12, 1919, and began to build a formidable clinical engine. He recognized that clinical practice is the essential piece of the tripartite mission of academic medicine, providing the milieu for medical education, factory for new knowledge, and regional reference point for clinical expertise. The clinical milieu generates inquiry and provides a testing ground for the ideas and technology to improve healthcare, and it is the spiritual center of the organization. Clinical programs provide the essential deliverable of academic medical centers. The clinical enterprise is also the financial engine.

Since 1972, Michigan Urology has called its alumni group the Nesbit Society, not from ingratitude to Cabot, but out of respect to his trainee Reed M. Nesbit who became the first Section Head of Urology, after Cabot’s abrupt departure in February, 1930. Over the next 37 years Nesbit made Ann Arbor an epicenter for medical education and clinical innovation. Nesbit trained nearly 80 residents and fellows (we are still trying to determine the exact number), and an extraordinary number of them became leaders in academia and their communities. As a principal innovator and master of transurethral prostatectomy, Nesbit made Ann Arbor a destination for doctors wanting to learn the operation as well as for “patients in-the-know” to get treatment. A number of Cabot’s other clinical faculty also became internationally dominant figures in their newly evolving clinical arenas, of thoracic surgery, neurosurgery, and orthopaedics as well as general surgery, thus bringing the University of Michigan to the center stage of clinical medicine for the first time in its evolution. Nevertheless, Cabot’s vision of a synchronous multispecialty academic health system eluded the University because the hospital functions and professional units (the clinical faculty) were competitive rather than synchronized.

 

Three.

The Nesbit 2019 Scientific Day last month was packed: Peggy Pearle from UT Southwestern in Dallas (above, with Stu Wolf from Dell Medical School in Austin, and Rod Dunn from our Dow Health Services Division) was featured as our Nesbit Visiting Professor with one talk on controversies in medical management of stones as well as another on ureteroscopy; UM President Emeritus Jim Duderstadt discussed the unique impact of the University looking back and looking forward; Jim Cogswell of the School of Art and Design gave a multimedia presentation on the mysteries of dark matter; Dan Dierdorf UM offensive lineman from the famed 1969 team and famed sportscaster presented his Michigan Memories; Stuart Wolf our own star faculty alumnus described the Michigan lessons he is deploying at the new Dell Medical School in Austin, and our departmental leaders gave updates on their divisions including Program Director Kate Kraft and CopMich Co-chair Jens Sønksen. This writer presented Centennial Thoughts and Ganesh Palapattu gave the State of the Department address. We had many wonderful returning alumni and I wish I could have shown them all on these pages, but more pictures can be found on the Nesbit100.com website. I also wish we could have had our traditional alumni talks, but we deferred those for this special Centennial Program, save for Peter Fisher’s unique talk of his personal experience that was both terrifying and uplifting: Everyone should experience sudden cardiac death —- and live. [Below from the top: Dan Dierdorf, Pete Fisher between Will Roberts and Phil Sweetser, Ganesh & Manfred Stöhrer.]

Manfred Stöhrer from Germany, Jens Sønsken from Denmark, and Kash Siddiqi from the UAE travelled far for this meeting. Some of us had been with Jens just a few weeks earlier in Copenhagen, and our ties to him and his team in Copenhagen go back nearly 30 years. The association with Manfred is just as long, with strong ties through Ed McGuire (below) and myself. Our actual but geographically distant faculty included Sherman Silber, now adjunct professor from St. Louis (below with postdoc Yuting Fan – Fanny), and Brian Stork and Jessica Phelps of our Muskegon West Shore Urology practice.

We consider UMMS graduates, residency trainees and alumni, faculty, regional colleagues, and other friends of the Department of Urology as Nesbit Society members, and many joined us to enrich the meeting. Bruce Bracken, John Hall, Phil Sweetser, Betty Newsom, the Chang duo of Cheng-Yang and Ted, Mike Rashid, Dave Morris, the Taub duo of Marc and David, the Kozminski duo of Mike and Michael, C. Peter Fischer, Howard Usitalo, Stan Swierzewski, Charles Gershon, Charles Reynolds, Jay Hollander, Amy Li, Parth Shah, Hugh Solomon, Joanne Dale, George Schade, Noah Canvasser, Katy Konkle, Bert Chen, Tim Schuster, Craig Kozler with son Oliver, Pete Fisher with son Jake who was interviewing for medical school, Brian Lane, Herk Khaira, Atreya Dash, Ray Tan, Ron Suh, and Scott Gilbert. Rebekah Beach, Frank Begun, Tim Bradford, David Burks, Ward Gillett, David Harold, Will Johnston, Earl Koenig, Surendra Kumar, Amy Luckenbaugh, David Perlow, Paul Sonda, and Nick Styn. Ed Kleer and Elena Gimenez from St. Joseph’s Hospital. Samir Basata, Bob Isacksen, Andre King, David Lutchka, Konda Mouli, Eric Stockall, and David Wenzler. UMMS alumnus Richard Tsou came from Hawaii Pacific Health. Jim Peabody and Nesbit alum Hans Stricker from Henry Ford Health System. From East Lansing we were honored to have Shirley Harding from Michigan State and Nesbit alum Len Zuckerman and Sparrow Residents Margeaux Dennis, Eric McKeever, Andrew Schwinn, Alex Shannon, and Ross Voelker. David Miller won the Konnak Faculty Service Award.

The evening reception at Zingerman’s Greyline event space at the Marriott was terrific with Thad Polk and Red Berenson who offered stories of hockey and Putin. Next year’s meeting will conclude this year-long Centennial Celebration of Michigan Urology and will center around the Wisconsin football contest. The dates will be September 24-26, 2020.

 

Four.

The game. The tailgate at Nub Turner’s GTH Investments provided a more relaxed social gathering point than the scientific program of the previous day. With the concurrent Homecoming Weekend and Parent’s Weekend, Ann Arbor was hopping. The victory over Iowa was a modest win, and it was largely won by our defense. The B-52 flyover was a crowd-pleaser, and the Veteran of the Game was a UM graduate named Thomas Houdek (below).

Michigan Urology has many notable veterans, although none more distinguished than Edward J. McGuire, the man who succeeded Jack Lapides in 1983 and hired me in 1984. Courtesy of Julian Wan we sat in the Club seats with Khaled and Mary Ellen Hafez (below).

 

Five.

Seasonal note. Autumn is fishing season in academic medicine when senior medical students prowl the nation’s training programs for residency education to select where they hope to learn their lives’ work. This process of residency training, postgraduate medical education, was quite informal in Cabot’s time, a century ago – a sort of “arrange-it-yourself” process for periods of time from weeks to years in length. Now the process has been standardized and is regulated by professional organizations including the AUA, ABU, ABMS, and ACGME.

Training programs simultaneously audition medical students in clinical clerkships in summer and fall of the senior years and interview them formally in fall and winter. Each party then submits their “rank lists” to a national site and matches are made for urology residency training positions. The process of interviews, selection, and then the actual residency training of 5-8 years is delegated to the Program Director, a position that has grown increasingly complex over the years since the terms of Gary Faerber, Khaled Hafez, and now Kate Kraft. Selection, education, and supervision of residents requires a small village of helpers and Kate is assisted by Sapan Ambani and a team of committees. This year Michigan Urology had over 375 applicants, offered around 66 interviews, and will end up matching with four trainees who will begin their residency training next July 1. Michigan Urology matched five last year, one of whom will have an 8-year period that will include a substantial research component, and this is Joel Berends. Ganesh, Khaled, Kate, and Sapan plan to alternate 4 and 5 year classes.

 

Postscript.

Vaughan’s reply to Shattuck. Only two days after Shattuck’s revealing response to the dean’s reference inquiry, Vaughan replied:

“My dear Friend:-
I am fully aware of the fact that Dr. Hugh Cabot being as strong a man as he is has made enemies and their criticisms have not failed to reach my ear, at least some of them. However I believe in Dr. Hugh Cabot and am greatly pleased that the prospect lies before me of having him as my colleague in work which I believe to be of the greatest importance to the future of American medicine. I congratulate myself and my school upon being able to obtain his services.

I wish to thank you for your words of sympathy. I had five sons in the Army and it seemed that the good fortune of having all of them returned to us was about to be accomplished. My eldest son was Chief of the Medical Service in the Roosevelt Hospital at Chaumont during the entire period of the war. After the armistice he was detailed to work up typhoid fever in the American Expeditionary Force. He had collected all of his data and was on his way home when he was accidentally drowned in a small river in France. It is the first time that death has visited our family. Time alone will assuage the sorrow but words of sympathy from such a dear friend as you will do much to mitigate our sorrow. Yours sincerely, V.C. Vaughan” [letter below]

 

PPS

In little over a decade Cabot brought the University of Michigan Medical School into the top tier of academic health centers. He recognized that a superb, attractive, and financially robust clinical engine was at the center of medical academia and he delivered on that necessity. Yet he spent down political capital rather than building it and he had a tin ear for the faculty and staff he led; it was not quite like his successful, albeit shorter-lived, experience as commanding officer at the Western Front of WWI. His successors in urology at Michigan continued to build one of the finest urology programs in the world, and Cabot surely would have been astonished to see what it looked like 100 years after he first set foot in Ann Arbor as its one and only urologist. [Below: Faculty, residents, alumni, guests at Nesbit Society meeting 2019.]

We thank those who joined us for this kick off for our Urology Centennial Celebration and invite you and those who couldn’t make it this year to the conclusion in 2020, September 24-26.

Best wishes as we begin November, 2019.
David A. Bloom
University of Michigan, Department of Urology, Ann Arbor

October incongruities and congruities.

 

Matula Thoughts 

Oct 5, 2018

October incongruities & congruities.
3813 words

 

One.

October is an odd month, not just with its odd number of days and shortening hours of daylight, but with unpredictable weather shifts including tropical cyclones, the Atlantic hurricanes and Pacific typhoons. Autumn is already in progress and Michigan is fortunate to witness spectacular foliage displays that peak this later this month. October lacks much in the way of major national holidays. Columbus Day, October 8 this year, is observed variably, in some states, Puerto Rico, banks, school districts, the Postal Service, federal and state agencies, but not generalized nationally or celebrated at Michigan Medicine.

Columbus Day had its start when the Tammany Society in NYC and the Massachusetts Historical Society in 1792 celebrated the 300th anniversary of the Columbus landing. A century later, President Benjamin Harrison similarly highlighted the 400th anniversary. Harrison, notably, was the only president (so far) who was the grandson of a president. Columbus Day became a state-level holiday in Colorado in 1907, in 1934 Franklin Roosevelt designated October 12 a national holiday, and since 1971 it has been set on the second Monday of October. The ambiguous details of European “discovery” of America, problematic from the indigenous people perspective, makes it unlikely that Columbus Day will have a long future as a national holiday. Alternatively, Hawaii celebrates Discoverer’s Day and Vermont declared it Indigenous Peoples’ Day. Native American Day is celebrated by California and Nevada on the fourth Friday of September, while in South Dakota on October’s second Monday. Tennessee observes American Indian Day on the fourth Monday of September and other countries in the Americas have their own origin celebrations.

University homecoming events provide other respites in October, although our Urology Department held its Nesbit Alumni reunion prematurely last month, nearly colliding with our biennial Dow Health Services Research Symposium due to coordination with autumn scientific meetings, religious holidays, and the dominating effect of the home football schedule relegating the 2018 Nesbit Meeting to September’s Nebraska game.

October ends with Halloween, an ancient Celtic harvest tradition, now centered on costumed children prowling their neighborhoods for treats, ostensibly as bribes to withhold pranks. Carved pumpkins or turnips become jack-o’-lanterns signaling target-rich households. Pumpkins are more octagonal than spherical to my eye and Halloween face-carving liberates pumpkin fruit for pies and pepita snacks. [Above: Irish Halloween turnip lantern, Museum of Country Life, Turlough Village, County Mayo, Ireland. Courtesy, Wikipedia. Below: October 2, 2018, Dee Fenner and Red Maple tree, outside Dean’s wing.]

 

 

Two.

Recollections of last month include the opening of Michigan Medicine’s Brighton Specialty Center, a large organizational effort led by John Wei, yielding 300,000 square feet of new clinical space. Anne Cameron did three of the first cases in the Brighton Center for Specialty Care operating rooms. [Above: John Wei at pre-opening ceremony. Below: Anne & OR team September 24.]

Our Dow Health Services Research Symposium #4, directed by Chad Ellimoottil and Lindsey Herrel, featured TED-style talks at Power Center.

[Above: Matt Nielsen University of North Carolina with slide congratulating Lindsey and Chad. Below: Greg Auffenberg (Nesbit 2017), Brent Hollenbeck, Chris Saigal of UCLA, Jim Montie.]

The featured speakers and short abstracts and lightning presentations were first rate, including Preeti Malani and Ken Warner (below).

The flying microphone, shown below with Rod Dunn, livened up the atmosphere. Jim Dupree discussed the successful Michigan Urological Surgical Improvement Collaborative (also below).

The following week Chris Sweeney, of Harvard Medical School/Dana Farber Cancer Institute, gave the Jerry Weisbach Lecture, speaking on clinical trial insights regarding prostate cancer heterogeneity. [Below: Chris & Ganesh Palapattu.]

The Nesbit Reunion, later in the week at NCRC (above), featured Toby Chai, Professor of Urology at Yale (Nesbit 1994) as Nesbit visiting professor who gave two excellent talks.

Our own Matt Davenport was the Nesbit guest speaker. John Wei did a superb job, as Secretary-Treasurer, organizing the program and event. [Above: Toby & Matt. Below: John Wei & Sherman Silber N’73.]

Sherman Silber spoke on “Progress making sperm and eggs from skin.” We also heard Kevin Stone and Brian Stork from West Shore Urology. [Below: Dave Harrold N’1978, Surendra Kumar N’81, Dan Piazza N’79, C. Peter Fischer N’79.]

[Below: Utah Pete Fisher N’06 & son Mitch.]

The Nesbit Tailgate entertained alumni and friends from around the country and the victory over Nebraska completed the weekend. Next year, around this time, we will launch the Centennial of Urology at Michigan. [Below top: Meidee Goh, sister Lindee from Boston, husband David Fry; bottom: Yuting Fan, Sherman Silber, David Burk N’89 & brother-in-law Rupert Baily from North Carolina.]

Next year’s Nesbit Reunion, 2019, will open up the year-long Michigan Urology Centennial.

 

Three.

Octopus, octagon, octogenarian, and October come from the Proto-European h₁oḱtṓw stem for eight, an odd fact given that this is the tenth calendar month of the year. How this came to be is a curious quirk of calendar history.

Lunar phases provided the first “calendars” throughout most of human history, marking time between solar days and solar years using the moon’s regular phases. Lunar phases are still essential for fishermen and sailors to predict tides, noting big swings in tidal amplitude during full and new moons (spring tides) and lesser differences during the quarter phases (neap tides). Etruscans and Romans approximated 8-day weeks to lunar cycles to coordinate commercial markets, political affairs, and holidays, although some fudging was necessary each year to match the solar cycle. An early Roman calendar ran from March through December with lunar cycles that filled up 304 days, exclusive of 51 winter days during an “unorganized expanse” of slack time. [Wikipedia entry Nundinae.] The ten calendar months of Romulus were then: Martius, Aprilis, Maius, Iunius, Quintilis, Sextilis, September, October, November, and December.

Julius Caesar gave us the Julian calendar, bringing Roman calendar years into closer agreement with solar years. He implemented the new system on January first in a year that he had no way of knowing would be 45 BC. The Julian Calendar offered three normal years with 365 days and an intervening leap year of 366 days, to make up for the inexact match of solar days to solar years. The leap day was doubled every fourth year to maintain solar synchrony, but nevertheless the calendar gradually lost its alignment with the solar year and by the time of Pope Gregory XIII in 1582, the asynchrony had drifted to 10 full days. Lawyer and law teacher in his earlier career, Ugo Boncompagni was summoned to Rome by Pope Paul III and served Paul IV and Paul V before election to Pope himself. His term was one of church reform, largely in response to the Protestant Reformation. [Below: Pope Gregory XIII portrait by Lavinia Fontana in list of extant papal tombs. Wikipedia.]

Gregory XIII refined the Julian Calendar by advancing the calendar that year so that 4 October was followed, the next day, by 15 October and using leap year spacing to make the average year 365.2425 days long. The Gregorian Calendar, fixing the 10-day drift and shortening the average year by 0.0075 days, is widely used throughout the world today for business and government. Because of Gregory XIII, the October of 1582 lacked a 5th day and nine others in between. The credit for the math involved belongs to Aloysius Lilius, an Italian physician and astronomer, and Christopher Clavius, a German Jesuit astronomer and mathematician.

Science has proven the actual length of solar days vary, due to tides sloshing around and slowing rotation of the Earth. The solar year (tropical year) in 2000 was 365.24219 ephemeris days, ephemeris time (ET) being defined by orbital period rather than axial rotation of Earth. The Système International (SI) divides an ephemeris day into 86,200 SI seconds. For most landlubbers lunar phases have limited utility, although they still show up on modern wrist watches, that keep us on time.

 

Four.

The regular weekly focal point of our department is 7 AM Thursday, regardless of month, when residents and faculty assemble for conferences where each summer a tide of 4th year medical students begins as rotating “clinical clerks” begin to audition for residency training slots. Students spend a month with us in clinics, hospital rounds, operating rooms, and then make individual presentations at Grand Rounds, having been directed and mentored by residents, fellows, and faculty. The tide recedes when nationwide formal interviews begin in October. [Above: Thursday 7 AM conference.]

Out of around 340 students who apply, around 20 clinical clerks, and 47 who interview, we will match 4 students who will spend their next five years or more with us. The candidate pool is very strong academically and in terms of individual personalities, life experiences, drive, and talents, these students are the best of the best of medical students. The proof is seen in our residents.

It is a tough time to be a medical student and entering medicine. Most students have accumulated egregious debt in the form of student loans. This fact is a black mark on our society. There is little excuse for a large medical school tuition bill, students create enough personal debt with living expenses alone during medical school. Society, particularly that of advanced industrialized nations, can afford to teach its next generation of health care workers. As it is, young doctors spend large fractions of their income paying back their debt (with interest) to banks and other funding sources – money that they would otherwise pump back into the economy through local stores, car dealers, home purchases, and Amazon. Philanthropy too would be served because former trainees in their first years of practice would be more likely each year to give a hundred bucks or so to the institutions that taught them (and even to the Nesbit Society), thus developing “a habit of giving back” rather than trying to stay afloat in the tsunami of educational debt.

The uncertainty of health care economics adds to the difficulty for students, and massive regulatory changes coming from the federal government place academic medicine and all of health care at risk, perhaps the greatest risk in our time. Yet, all times have been tough, and many of the best and brightest people continue to choose medical careers.

 

Five.

Political campaigning heats up in October with elections next month for governor, state legislators, other regional officers, one third of the US Senate, and the US House of Representatives. Voter turnout in the US tends to be around 58% of eligible voters in national presidential election and 40% in mid-term elections. Even less turn out in odd years, primaries, or local elections, indicating that Americans take the responsibility of democracy far too lightly. This fact should disturb us at least as much as the idea of foreign governments messing with our processes (that’s what rough opponents do – so why are we surprised and apparently so defenseless?) Below is a chart from the U.S. Census Bureau.

Our predecessors worked hard and against odds to create a government of the people, by the people, and for the people. The Declaration of Independence is a beautiful and aspirational document that explains why people should be entrusted to their own destiny, The Constitution creates a working framework for government, and its Bill of Rights presents a list of individual protections from authority (with some nonsense that politics mixed into it). A greater cynic might argue, given the voter turnout data, that today’s citizens are not working hard enough to protect foundational elements of western society.

On the other hand, deception has its moments and admits many self-serving hucksters and bad actors to the corridors of power. Voters are often attracted to bright shiny celebrities, single issue extremists, or deceptive campaigns. Trickery is part of the human confection, one classic example being the Trojan Horse of Homer’s stories, although new technologies magnify the possibilities of deception and crowd manipulation. Technology aside, our society has failed to properly educate an informed citizenry capable of critical thinking. Biologic trickery takes many forms, and the octopus is one of the most versatile masters, using camouflage, mimicry, threat, shape-shifting, and environmental opacification. While octopi (scientific order Octopoda) may be the biologic champions, humans are good learners.

[Jens Petersen. Image of greater blue-ringed octopus, Hapalochlaena lunulata. Tasik Ria, North Sulawesi, Indonesia GFDL license. Wikipedia.]

 

Six.

Octoberfest. Beer and political campaigning mingle in October. Octoberfest, as a celebration, dates back to 12 October 1810, when citizens of Munich attended festivities around the royal marriage of King Ludwig I to Princess Therese. Münchners, Munich’s community-folk, gathered peacefully to drink beer, watch horse races, and enjoy a day off work, unless they were helping with the crowd, distributing the food and beer, or organizing the races. Civilization requires organizers, workers, and leaders.

Octoberfest has spread around the world as a respite from routine of work and a chance to celebrate as a community. For some people this is simply an excuse to drink beer, but others enjoy some civic sensibility. Beer and other spirits may help navigate the politics that necessarily attend all communities and the periodic stress of politicking to elect around 500,000 state and national public officials.

Leadership is an unfortunate necessity of human affairs, and over the course of documented history it is evident that most leadership has been self-serving, foolish, and extended the sum total of human misery. Nevertheless, seven billion humans need forms of leadership to organize sports, workplaces, community events, local governments, geographic regions, religions, and nations.

The U.S. Congress on 23 January, 1845 passed “An act to establish a uniform time for holding elections of President and Vice President in all the States of the Union.” The Tuesday after the first Monday of November was selected and that date continues to this time. Federal elections occur only in even-numbered years, and presidential elections take place every four years. October, the heaviest month of campaigning, is exhilarating for many people as evidence of the aspiration of “government of the people, by the people, and for the people.” Election day is a public holiday in some states and territories, but not Michigan. November 5 is our next election day.

 

Seven.

October fiction. October Country, the name of a 1943 Ray Bradbury collection of stories, conveys a sense of the oddness of October. The introductory “mini-story,” The Grim Reaper, in the modern paperback version, is a stark commentary on modern humankind in the mid-20th century. [Bradbury. The October Country. Del Rey Ballantine Books, NY. 1996.]

Bradbury used the title, The October Country, as a metaphor for that time of the year when people and places become melancholy with thoughts and preparations for winter. His dystopian novel, Fahrenheit 451, imagines the dark winter of an authoritarian society where free speech no longer exists. The 1966 Francis Truffaut film version with Julie Christie was a classic in its own right. Bradbury (1920-2012), along with Isaac Asimov, Arthur Clark, Robert Heinlein, and Stanislaw Lem carried science fiction into the literary mainstream according to a 2012 obituary [Gerald Jonas, NYT, June 6, 2012.]:

“The futuristic world envisioned by Bradbury among others is coming fast upon us, compelled by the erosion of democracy and the ascendency of technology. We not be able to curtail the latter, but we should be shamed by our pathetic efforts as a species to build and disperse democratic institutions and human rights.”

Machine-learning algorithms, even those multi-layer “neural” networks capable of “deep learning,” in my opinion can ever equate to human intelligence. Programs and systems are built by people susceptible to particular ideologies, biases, “isms,” greed, and other intoxications that plague everyone and their clever systems invariable reflect some, but not all particularities. These algorithms are already in play in our lives and will become increasingly pervasive with autonomous capabilities in many sectors of our lives, however we must be cautious of accepting artificial intelligence (AI) as a substitute for human authenticity. How can AI distinguish between fact and true facts, given the mutability of fact and truth and their continual arbitration, in “real time,” by human values, science, and consensus? A cynic might argue that AI shouldn’t be expected to distinguish between facts and true facts if most humans can’t do so.

Ian Fleming’s final James Bond book, the 14th in the series, Octopussy and the Living Daylights, was a collection of short stories published posthumously in 1966, originally with just those two stories, but later including The Property of a Lady and also 007 in New York. The first story and provided the backstory for the film Octopussy, with Roger Moore in 1983. A pet octopus, owned by the villain, give that story its name and elements of the other stories found their way into other Bond films.

 

Eight.

October tides. Back in the times of the earliest wine and beermakers, days were defined by sunrises and sunsets, tides and lunar phases framed the weeks, and sun and star positions marked out months and years. It must have taken a leap of faith for early thinkers to convince themselves that something as far away as the moon could physically move the massive oceans of earth, but the tidal relationships to moon and sun were recognized as early as the second century BC by Hellenistic astronomer Seleucus of Seleucia who linked tides to lunar position, with height of tides depending on the position of the moon relative to the sun.

Tide tables were made for tourists in China in 1056 so that they could coordinate visits to the legendary tidal bore of the Qiantang River. Due to the mismatch in size between the Hangzhou Bay and Qiantang (Tsientang) River, this daily occurrence with 30 foot tides moving at 25 mph, can double in size when the moon and coincidental typhoons align. This has been celebrated for thousands of years during the 8th month of the lunar year, known as the Mid-Autumn Festival. [David K. Lynch. Scientific American. January, 1982. Alan Taylor. The Atlantic. Sept. 20, 2016.]

Newton may have been deemed a tidal bore when wrote the essay Discourse on the Tides, in 1616 in a letter to Cardinal Orsini and later used calculations and his theory of universal gravitation in Principia in 1687 to explain the tidal influences of sun and moon. Great Lakes tides at their greatest reach 5 centimeters, although much larger standing waves called seiches, caused by wind and atmospheric pressure, are mistaken for tides.

 

Nine.

Tecumseh, Harrison, and the Battle of the Thames. The Thames River in Ontario comes to mind in relation to a famous Native American who died on this day, October 5, 1813. We have many referrals for patient care from our neighboring town, Tecumseh, and while I vaguely recognized this as a Native American name, I knew little until I looked it up and learned this day is the anniversary of a battle in 1813 when Chief Tecumseh was killed at the age of 45. An American Shawnee, he was born in Ohio Country and he grew up amidst the American Revolution and the Northwest Indian Wars. He became a great leader, compelling orator, and staunch advocate for tribal unity.

Tecumseh’s War in Indiana Territory between his American Indian confederacy and the U.S. began with a confrontation in 1810 at Grouseland, the home of William Henry Harrison, governor of the territory. Conflict continued with a defeat for the multi-tribal confederacy at the Battle of Tippecanoe in 1811, and spilled over into the War of 1812 after Tecumseh formed an alliance with Great Britain that helped capture Fort Detroit. After the fledgling U.S. Navy gained control of Lake Erie in 1813, the British and multi-tribal confederacy retreated into Canada, where American Forces engaged them at the Battle of the Thames (also known as the Battle of Moraviantown) and Tecumseh was killed.

[Above: Tecumseh, attrib. Owen Staples. Toronto Public Library. Below: Tecumseh’s War map by Kevin Myers, Wikipedia.]

[Below: Battle of Tippecanoe. Alonzo Chappel Collection, Smithsonian Institute.]

With the death of Tecumseh, the confederacy collapsed and Detroit returned to American control, where only four years later the University of Michigan would be established. Most native Americans were eventually pushed west of the Mississippi.

Harrison considered Tecumseh remarkable, once calling him a genius. With soaring popularity after the War of 1812 Harrison became U.S. House Representative in 1816 and Senator in 1825, truncated by appointment as Minister Plenipotentiary to Gran Columbia in 1828. He returned to private life in Ohio at his farm, but was prompted to make a few runs for presidency, ultimately winning and becoming ninth American President in 1841, the last president born before the Revolution.

Harrison’s term was short-lived as Harrison was sworn in on 4 March 1841 and died of pneumonia a month later. Vice President John Tyler assumed office, but a constitutional crisis concerning succession lingered for more than a century until resolution by the Twenty-fifth Amendment of 1967. Tyler was the son of Founding Father Benjamin Harrison V and the paternal grandfather of 23rd U.S. President Benjamin Harrison, who nationalized Columbus Day.

It might be argued that the choice of our ninth president was a risky one from the point of health vulnerability, at age 68 he was the oldest sworn into office until Ronald Reagan in 1981 at 69. On the other hand, far younger presidents and major political leaders have been cut short by disease or assassination, so perhaps age should be a minor consideration for long range leadership. Representative democracy seems a far better method of leadership selection than royalty, birthright, or sectarian succession, but genetics (or epigenetics) always seems to be lurking behind the scenes as the American presidency has shown through Adams, Harrison, Roosevelt, and Bush.

 

Ten.

Octopus traps and Halloween spiders. Matula Thoughts often seeks threads or themes, sometimes risking belaboring a point or putting too fine an edge on a detail, such as comparing pumpkins to octagons, or relating October to medicine. Of course, October 16, 1846 was the first demonstration of general anesthesia.

A stretch to the octo stem brings in Takotsubo cardiomyopathy, a non-ischemic heart crisis of sudden temporary weakening of the muscle also known as stress cardiomyopathy, transient apical ballooning cardiomyopathy, or the broken heart syndrome, and leading to acute heart failure, lethal ventricular arrhythmias, or ventricular rupture. Most cases (85%) are set in motion by severe physical or emotional distress that causes myofibrillar degeneration. The first studied case was by Sabo et al in Japan, reported in 1991, and the name came from the traditional octopus traps used by Japanese fishermen, setting them out when the tides were favorable. [Yoshihiro YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy. Circulation. 118:2754, 2008.] [Below: octopus traps, Wikipedia, public domain.]

Octopi aside, eight doesn’t have a heavy presence in biology, Stedman’s Dictionary expends barely a half a page to words beginning with oct. Although spiders and ticks (larger category = class, Arachnida) have eight legs, octo hasn’t tainted their names. Spiders rank seventh in species diversity among all organisms, with nearly 90,000 species compared to 300 species of octopi, and our single human species. Spiders (biologic classification order, Araneae) have enormously complex genomics and have a universal ability to make silks and venoms. [Pennisi. Science. 358:288, 2018.] Spiders scare kids and are completely congruous with Halloween, so be prepared with shock, awe, and a basket of treats when permutations of 8-legged creatures knock at your door at the end of this month. [Below: Marvel Spider-Man symbiote suit.]

 

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

Gaps

Matula Thoughts Feb 2, 2018

 

Gaps, stories, & authenticity

3707 words

 

(Above: MIA this February)

One.         

Minding the gap. February is a gap month, adjusting for the tiny discrepancy between solar years and calendar years by an awkward change that lengthens the month once every 4 years. The next 29-day adjustment will happen in 2020.

Missing this month is the full moon like that which happened two days ago and coincided with a super moon, a blue moon, a blood moon, and a total lunar eclipse (the picture above was taken last year). Full moons usually happen monthly, sometimes even twice a month, with the second of the full moons called a “blue moon,” although having no blueness whatsoever. The super moon refers to the optical effect of the moon being “super close” to the Earth. The blood coloring  relates to lighting effects from the lunar eclipse.

Given lunar periodicity of 29.53 days, February is the only month in which a full moon gap can happen. This last occurred in 1999 and will happen next in 2037.  A similar gap occurs in occasional Februarys with the new moon, as last in 2014 and next in 2033. [Macdonald. J. Brit. Astron. Assoc. Dec 1998. p. 324.]

February, in the Midwest, also provides a gap between the celebratory early days of winter and the promise of spring rejuvenation in March or April, before May contingent perhaps on today’s groundhog forecasts from Punxsutawney, Pennsylvania. If you are in Punxsutawney today and travel east along Interstate 80 near the interface between Pennsylvania and New Jersey you will encounter another type of gap, the Delaware Water Gap, where the Delaware River cuts through a ridge of the Appalachian Mountains.

Last summer I passed through a second geological gap after being stuck in traffic in the Rockies along with cars, trucks, and Greyhound buses backed west of an accident on Interstate 70 (below).

I had been returning from a continuing medical education course that Quentin Clemens, Brent Hollenbeck, and Jeff Montgomery had organized conveniently close to excellent fly fishing opportunities that would be warmly relished this cold month. This summer, by the way, will likely be a gap year for their course, but with encouragement they might reprise it in 2019, the year Michigan Urology begins its Centennial celebration.

The specific phrase, mind the gap, came into play exactly fifty years ago, in 1968, when London Underground leadership automated and standardized the warnings that drivers and local station attendants had been giving to passengers regarding the gaps between the station platforms and train doors. Because the gaps were sometimes dangerously large, an automated short announcement was planned with digital technology. The AEG Telefunken Company supplied the equipment and sound engineer Peter Lodge recorded test phrases intended to read later by an actor. After the actor demanded royalties, the thrifty London Underground deemed Lodge’s own test readings of “Mind the gap” and “Stand clear of the doors please” good enough and ultimately implemented them in stations in 1969.

Minding the gap is a useful metaphor for medical professionals and residency trainees. The gap between conjecture and truth is the workplace of the health sciences and the rapid advances of knowledge and technology create new inevitable gaps. Additionally, complex systems, health care economics, and divided loyalties create tensions that force ethical and moral challenges. An editorial in JAMA by Donald Berwick last year highlighted some of the moral choices confronting today’s doctors, explaining that the gaps between choices come in three tiers, personal, organizational, or societal. [Berwick. JAMA. 318: 2081, 2017.]

 

Two.

London Underground dates back to 1854 when the Metropolitan Railway gained permission to build a subterranean system and began to evaluate digging methods in test tunnels, but it wasn’t until January, 1863 that it opened the world’s first underground railway, which ran between Paddington and Farringdon Stations. Steam locomotives hauled wooden gas-lighted carriages. A second line, The District Line, between Kensington and Westminster, opened in December, 1868. The first underground lines were trenches that were “cut and covered,” in a manner like the setting of the Terra Cotta Army of Qin Shi Huang 2100 years earlier. Newer methodology of deeper bored circular tunnels, avoiding the need to involve surface property owners, began with electric locomotives on the City and South London Railway between King William Street and Stockwell in 1890. The deep tube system expanded and by the time of the “Mind the gap” recorded announcements, the London Underground map had become one of the iconic graphics of the 20th century. Some versions of the map noted the distances involved, vertically and horizontally, for the more egregious gaps.

Composite_Beck_and_2012_tube_map

[Wikipedia. The left side shows the 1933 Beck map and the right side the Underground map as it appeared in 2012.]

The Darkest Hour, a new film about the gap between England’s meager armed forces in 1940 and Hitler’s military advance in Europe shows a fanciful scene where Churchill takes the Underground to Westminster one day seeking to understand the “will of the people.” His imagined conversation with the working people on the train bolsters his courage to resist rather than capitulate to the overwhelming and imminent threat. Churchill goes on to deliver his first galvanizing wartime speech. In the film two political opponents grouse: “What just happened?” one asks as parliament erupts in patriotic cheers. “He [Churchill] mobilized the English language,” comes the reply, “and sent it into battle.” Creative devices of the cinema notwithstanding, it’s hard to imagine what today’s world would be like without Winston Churchill’s leadership in that precarious year.

 

Three.

Fictional views of the world help us understand it more accurately and deal with it more effectively. When fiction artfully imagines facts and relationships and renders them in coherent stories with enough historical fidelity and realism the past, present, or even the future become clearer. The Darkest Hour did this effectively for those dark days of 1940, when England found itself unprepared for a re-armed and hostile Germany. Although the Underground scene was fiction, it gave substance to the reality that Churchill was able to tap into the will of the English people, understanding that their values, hopes, and dreams were quite distinct from the views of the rarified aristocracy that surrounded him and had ruefully shaped English policy until that moment. Churchill, like his peers and advisors, had limited contact with ordinary, working people, but he had enough sense of them to gain an imagined understanding of their aggregate intent on the choice between surrender or fight. Furthermore, his inspiring speeches at the right moments tilted the scale further against appeasement and surrender. While the Underground scene might make historians grumble, the fictional device artfully illuminated Churchill’s likely state of mind.

The 1993 film, Groundhog Day, offered more outlandish fiction, giving an imaginative spin to the Punxsutawney myth. A successful musical version premiered in London at the Old Vic in 2016. This story is a fiction about a fiction. Yet, who hasn’t wished for moments like Bill Murray’s Groundhog Day where time repeats itself, offering us another chance, or like “a glitch in The Matrix,” and as Yogi Berra is reputed to have said: “Déjà vu all over again.”

 

Four.

Our species, Homo sapiens, is not only defined by its stories, but stories shaped our emergence from the earlier members of our genus Homo, if you accept a Darwinian point of view. Allen Lichter, former UMMS Dean, sent me a book recently that elegantly consolidates our specific human story. Aptly named Sapiens and written by historian Yuval Harari, the account tells how our genus, Homo, evolved 2.5 million years ago from an earlier and now-extinct genus of great apes in East Africa and set out to see and change the rest of the world. Some kindred species, Homo neanderthalensis, evolved in western Eurasia of the Ice Age while others, Homo erectus appeared in Eastern Asia and survived for 2 million years. Homo soloensis evolved on the island of Java, Homo floresiensis on Flores, and Homo denisova in Siberia were also members of our category of biologic classification, the genus. Evolution also continued in East Africa with other competing species in our genus: Homo rudolfensis and Homo ergaster, along with us, Homo sapiens.

Harari gives reasonable evidence that storytelling was central to the emergence and dissemination of Homo sapiens, who eventually replaced all the other species of the Homo genus, although collecting bits of their DNA along the way. All hominoid species existed in communal groups that must have depended on some form of verbal communication, but Harari indicates the language skills of H. sapiens were superior and in time gave total competitive advantage to our species of humans: “The ability to create an imagined reality out of words enabled large numbers of strangers to cooperate effectively.” [Harari p. 32]

The earliest storytelling logically was a matter of gossiping and rumors related to clan folk, hunting, competing clans, predators, seasons, and climate. Storytelling expanded, perhaps around campfires, into durable tales of myth, history, and fantasy. Without the advantage of scientific thought and verifiable information early story tellers undoubtedly relegated competing some clans to barbarian enemies. Some of these may legitimately been other human species, although as opposed to traditional ideas that different species could not breed, evidence is clear that successful interspecies mingling occurred in the last 100,000 years before the other human species became extinct.

For the last 10,000 years Homo sapiens has been the sole human species. Historical ideas of polygenesis have been effectively debunked – there is only one human kind, although 7 billion of us have myriad ethnic origins, ideas, experiences, hopes, and dreams. Diversity is an uncontestable true fact, and equity and inclusion are mandatory to our survival as a species. John Kennedy once was reported to have said: “Our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s future. And we are all mortal.” [Commencement Address at American University, Washington, DC. June 10, 1963]

Today’s world is cosmopolitan in fact and by necessity.

 

Five.

Today, February 2, has interesting links to the past. Notably, in 1887 in Punxsutawney, Pennsylvania, Groundhog Day began on this day. February 2 in 1901 was the day of Queen Victoria’s funeral. My grandfather recalled that he watched part of it from a rooftop in London, guessing that he was around seven years of age at the time. On this day in 1922, the book Ulysses by James Joyce was published, resetting the line between pornography and “acceptable” literature. In 1925, on February 2, dog sled relays carrying life-saving diphtheria antitoxin reached Nome, Alaska when all other access was impossible. This superhuman feat, a half-century later, inspired the Iditarod Race. Balto, the most celebrated of the original relay dogs, is immortalized in a statue in New York’s Central Park and his remains, preserved by taxidermy, are at the Cleveland Museum of Natural History.

These curious bits of information are facts that can be authenticated, for the most part. The late Don Coffey used to tell his students to learn to distinguish facts and true facts. What he intended with that admonishment was the recognition of authenticity in the pursuit of truth, authenticity being a state of worthiness of acceptance or belief by conforming to true fact.

Facts (and data) have some degree of relativity as Coffey knew well, they may change as new information is gained. Truth is something greater than fact, a higher degree perhaps of accuracy or authenticity. Something authentic is genuine, factual, truthful, or honest. As fanciful as the idea that a groundhog could predict the remaining length of winter or the notion that someone could be trapped in a repetitive time cycle, there is something authentic in the human aspiration to find easy ways to forecast the future (much like ancient uroscopists) or to have a chance to repeat a day in one’s life to achieve a better outcome.

 

Six.

Human nature seeks truth and its embodiment in personal conduct, integrity, is the basis of successful social interaction. The line between authenticity and inauthenticity can be difficult to discern and it can change. As we become informed that facts we had previously taken for “true” are found to be inaccurate, we are playing the intellectual game of science. More generally, this is the game of life as Homo sapiens. New information – observations in life – reasonably cause us to reset beliefs and values. It is no moral lapse or inauthenticity to discard facts when better facts are discovered based on new information, rather this is the natural human arbitration of the world.

Inauthenticity is another matter, being usually deliberate deception with antonyms that include counterfeit, inaccuracy, infidelity, deception, exaggeration, erroneousness, falseness, miscalculation. For a physician, nurse, PA, MA, researcher, other health care worker, or patient, the presumption of absolute authenticity is the basis of daily transactions. This is no less true for a historian, English professor, geologist, or physicist. Yet facts and stories are likely to have different interpretations or aspects to them. We arbitrate “truth” through collaboration with knowledgeable peers, or other sources of information. Such calibration is the nature of the scientific process, but it is more generally at the heart of all the social and intellectual interactions of human civilization.

A storyteller’s success is a matter of telling an authentic story. The story may be fact or fiction, but in either instance, the ability to make it ring true to a discerning ear is the hallmark of success. A successful factual writer, such as a journalist, will collect facts and study relationships in order to weave them coherently and artfully. The writer must strip away non-essential information or information perceived as inaccurate or misleading to create a story that is clear, accurate, and authentic to the reader.

The distinction between authenticity and inauthenticity is more complex for the writer of fiction, the value of which is to entertain and inform. Good fiction is authentic when it creates a story that rings true to readers in terms of realistic dialogue, details both relevant and accurate, and narrative that is clear. In the best instances, good fiction not only illuminates reality, but it distills it to capture and enhance its essence.

 

Seven.

Churchill’s language. Years ago, when the Society for Pediatric Urology was held in New York City and Bernie Churchill was president of the group, a well-known Winston Churchill authority and impersonator, James Humes, appeared as the surprise dinner speaker. When Humes described Churchill’s approach to speechwriting, the ideas resonated enough to write them down. Curiously, I’ve been unable to verify these in anything I’ve read of Churchill since then, so I can’t promise them as “true facts.”  Nonetheless, they ring true to me:

  • Start strong
  • Simple language
  • One theme
  • Paint a picture
  • End with emotion

In his own writings, Humes himself is the source of some good quotes.

  • The art of communication is the language of leadership.
  • Every time you have to speak you are auditioning for leadership.
  • Most speakers speak ten minutes too long.

If you want to explore Churchill and Humes further, a book Humes wrote in 2001, Eisenhower and Churchill: The Partnership That Saved the World, is well worthwhile.

 

Eight.

The Tet Offensive began fifty years ago and should be recalled for many reasons, but none less than it offers important lessons in leadership. Last year on these pages we told some of the story of Larry Hawkins, a young man from Detroit, who was one of the thousands injured during the Tet Offensive and how he came to the Ann Arbor Veterans Hospital paraplegic and deteriorating from urosepsis due to a neuropathic bladder. Jack Lapides saved his life by performing a vesicostomy, that also gave Larry personal independence. Larry went on to become a lawyer and influential public servant in Florida. After a distinguished career that included advocacy for the rights of the handicapped, Larry passed away a year ago and was buried at Arlington National Cemetery last summer. We had come to know of Larry through the efforts of his sister in contacting us for stomal supplies, that were becoming harder and harder to obtain for the Lapides vesicostomy, an operation that was life-saving in its day, but has been largely replaced by other management techniques.

Fifty years ago, in January 1968, when the combined forces of the Viet Cong and the North Vietnamese People’s Army of Vietnam launched surprise attacks on dozens of cities, towns, and hamlets throughout South Vietnam, the tide of the war began to shift. My professional education had begun amidst the Vietnam War, when we still had a national military draft, but my service was deferred via the Berry Plan until I completed my training. By then the draft and war had ended, but my service was still mandated and I was assigned to Walter Reed Army Hospital.

For the next few decades the collective American consciousness wanted to forget Vietnam and its many lessons, something that was easy to do for most people whose bodies, minds, and families had escaped the war’s sequelae. Nevertheless, occasional great memoirs gained public attention, including the Things They Carried by Tim O’Brien and Robert McNamara’s book In Retrospect. That latent period passed with the recent Ken Burns encapsulation, The Vietnam War. These books should be required reading for every American citizen. Continuing with the de facto “movie review theme” this month, we call attention to The Post, a current film that combines fact and fiction to tell an important and authentic story about The Washington Post and The Pentagon Papers.

 

Nine.

The_General_(C-1._S._Forester_novel)_book_cover

Leadership. A much older book recently came to public attention as a favorite of General F. John Kelly, Chief of Staff for the President. The General, by C.S. Forester is described as the classic example of leadership during WWI, but its lessons transcend any era. Written as fiction in 1936, its authenticity made it a best-seller and it tells the timeless tale of leaders who fail by fighting this year’s war with the tools and tactics of the last decade’s war. This book impressed Churchill, as well as Hitler according to Forester. Kelly singles The General out as an example of the importance of what he calls “Professional Reading,” a necessity for anyone aspiring to competence in their work. An article in Foreign Policy quotes Kelly:

“When I came back in the Marine Corps as an officer — close to my first days as a second lieutenant — I ran into a fellow named Capt. Ed Wells, a Harvard-educated, upper-crust guy. That first day I knew him he started talking to me about professional reading and how the real professionals read and study their professions. A doctor who doesn’t read peer articles and stay attuned to the developments in his field is not the kind of doctor you would want to go to, and the same is true for officers in the Marine Corps. He got me going on reading, specifically focused on military things, and I just never stopped. When I read a new book I wrote a notation in the front of the book what billet I was in, the date I finished reading it, and where in the world I was…

I’ve read this book [The General] every time I got promoted just to remind myself of the effect. I’ve noted where I was when I finished reading it the last time, then when I read it again I will try to remember what it meant to me as a major and, depending on as you get older and higher in rank, it’s a different book every time you read it. When a lieutenant reads that book it’s different from when a lieutenant general reads it. And I think the same is true for every book. So it’s just kind of a fun thing I’ve done over the years and with this book in particular just to remind me of the critical importance of thinking.” [Ricks. Foreign Policy. April, 2017. Reprinted, by permission, from Adm. James Stavridis, USN (Ret.) and R. Manning Ancell, The Leader’s Bookshelf (Annapolis, Md: Naval Institute Press, © 2017).]

 

Ten.

The Greyhound bus line company. Travelling through the Delaware Water Gap this winter on Interstate 80 or stalled in traffic last summer on Interstate 70 along a cut through the Dakota Hogback west of Denver I saw a number of the ubiquitous Greyhound buses. Greyhound is as synonymous for intercity travel in North America as the Underground is for intracity transportation in the United Kingdom. Greyhound’s first route traces back to 1914 in Hibbing, Minnesota when Carl Eric Wickman, a failing Hupmobile car salesman, used his last remaining 7-passenger vehicle to transport iron ore workers from Hibbing to the town of Alice, known for its saloons, at 15 cents per passenger. The next year Wickman teamed up with Ralph Bogan who had a transport service between Hibbing and Duluth. The newly named Mesaba Transportation Company had a positive margin of $8000 that first year. Through mergers and acquisitions of networks, Mesaba grew.

The Greyhound name appeared informally on the inaugural run of a segment from Superior, Wisconsin to Wausau, Wisconsin when the local operator of the affiliated Blue Goose Line run, Ed Stone, saw a reflection of his bus as it passed by a shop window and the moving image reminded him of a greyhound dog. Stone later applied the name to his entire network. By 1927 the entire Wickman system was transcontinental and by 1930 it had consolidated 100 bus lines into the Motor Transit Company, that was soon rebranded the Greyhound Corporation. In 2007 Greyhound became a subsidiary of the British FirstGroup transportation company, although Greyhound itself remains based in Dallas. While most large metropolitan subway systems have consolidated into public utilities the interurban bus lines have remained private.

Old Depot

The Bus depot in Ann Arbor serviced interurban bus lines including Blue Goose, Greyhound, and Shortway from a little building (above) until September, 1940 when it was replaced by a state-of the-art facility with 62 seats, a telegraph booth, a ticket office, a baggage room, and a 12-seat lunch counter.

Depot Story

Over the years, as Greyhound became the dominant carrier, the art deco building lost its luster through a number of renovations until 2014 when it was taken down to build the Marriott Residence Inn. The historically attuned developer, First Martin Corporation, retained the façade (below) and encapsulated the story of the bus station on the lovely visual displays, seen above.

Bus depot facade

Residence Inn

……………………………………..

It’s been a challenging winter, but spring is not far away.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

 

Dancers and Michigan’s third century

Matula Thoughts Sept 1, 2017

3866 words
Dancers & Michigan’s third century

One.

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

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

 

Two.

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

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

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

 

Three.

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

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

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

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

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

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

 

Four.

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

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

 

Five.

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

 

Nine.

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

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

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

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

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

 

Ten.

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

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

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

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

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

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

 

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

Secular thoughts of summertime

DAB What’s New Aug 4, 2017

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Summertime secular thoughts

3575 words

One.              

Summertime. Summer is busy for children’s surgeons. Well in advance of the upcoming summer, as early as winter, families schedule elective surgery for their children. Aesthetically, summer began for me in May when peonies opened up in the Nichols Arboretum adjacent to Mott Children’s Hospital. Meteorologically, summer started at the northern hemisphere solstice when the Earth’s axial tilt toward the Sun peaks with its highest position in the sky at the north pole (12:24 AM EDT June 24 this year). By now we are in summer primetime having enjoyed Farmers’ Market, resident/fellow graduation at the Art Museum, Ann Arbor Summer Festival, fireflies, Top of the Park, chiefs’ roast, July 4 fireworks, Art Fair, Chang-Duckett-Lapides visiting professorships, Zingerman’s outdoors, and other seasonal pleasures counterbalancing our jobs. [Above: Art Fair – Matt Lee, Lindsey Herrel, Rita Jen. Photo by Ted Lee]

[Above: UM Peony Garden & Mott; below: Art Museum graduation dinner for chief residents and fellows.]

[Below: boating on Huron]

[Above: Summer Festival. Charles & Julie Ellis, Rhiannon Giddens; below: hotdog line in front of Human Genetics Department with Joette Goudie, Lisa Turek, Pattie Postel, Sandy Heskett, Maranda Valentine, Phoebe Hankins, Liz Daniels, Marlene Muscott, Amanda Thatcher, Shelby Chase.]

All jobs are performances, some more complex than others, but no matter what the work may be individuals can bring art and professionalism to any job. What inspires performance? Ultimately, it is a matter of internal drive, the personal motivation to go beyond mere competence to achieve one’s best, to find excellence, to bring art to tasks. In earlier agricultural and early industrial societies people either worked for themselves or had their work regulated by ancient “carrot and stick” motivations. Frederick Taylor’s influential monograph in 1911, The Principles of Scientific Management, argued that managers should coordinate workers by using data, leading to the idea of managerial accounting.

In the modern knowledge economy, internal motivation (see Daniel Pink, Drive) and lean process thinking (Johnson & Bröms, Profit Beyond Measure) seem better ways to understand, stimulate, regulate and standardize work, as well as satisfy stakeholder needs rather than using carrots and sticks. For the multi-pronged mix of clinical care, education, and discovery of academic medicine, internal motivation is the key to high performance, quality improvement, value, standardization, and job satisfaction, all with art that inspires further motivation. Carrots and sticks may have been useful motivational tools in commodity commerce, but don’t satisfy the health care market nor improve the genre of medical practice.

 

Two.

Graduating urologists step into their next career stages this month. Katy Konkle joined a practice in Pueblo, Colorado, Ian McLaren is with a 5 -person urology group in Wenatchee, Washington, Duncan Morhardt stays with us for a year of research prior to pediatric urology fellowship at Boston Children’s Hospital, and Ryan Swearingen enters a practice in Indiana.

The work of physicians changed since I took that same step in 1980, moving from residency at UCLA to a staff position at Walter Reed Army Medical Center in Washington DC. My practice, like that of any urologist then, was spent mainly one on one with patients in clinics, at bedsides, or in operating room teams. Today, however, clinicians spend as much time focused on computers and keyboards as directly interacting with patients. A recent paper in Health Affairs demonstrates the tyranny of the modern electronic medical record demanding equivalent parcels of physician time spent at computers as facing patients. [Ming Tai-Seale et. al. Electronic Health Record Logs indicate that physicians split time evenly between seeing patients and desktop medicine. Health Affairs. 36:655-662, 2017] Computer interfaces proliferate in operating rooms today, but remain more tools than tyrants, although the imagery is ironic.

[Above: Alon Weizer’s OR with Joe Bloom by the patient; Below: Dr. Weizer at controls.]

 

 

Three.

Eighty years ago, this month, the head of the Section of Urology at the University of Michigan in the Department of Surgery published an important paper in the New England Journal of Medicine. This fact is doubly curious because it was a surgical paper in a journal of medicine and Michigan is hardly in New England. That journal, the “journal of record” for historical and contemporary reasons, attracted the most important medical papers internationally, a reputation still largely intact although challenged by other world journals such as The Lancet, British Medical Journal, and the Journal of the American Medical Association. Reed Nesbit’s paper had global significance, as TURP became the gold-standard solution for the common curse of benign prostatic hypertrophy. The surgical procedure was as much art as skill and Nesbit was the go-to TURP artisan of the time, attracting trainees and visitors from around the world. The centennial of urology at the University of Michigan (1920-2020) is approaching and the changes in urology, some emanating from the University of Michigan over those 100 years, are astonishing to consider. More largely, the changes in healthcare itself are enormous, and much of the change is due to massive expansion of the federal role.

 

Four.

The role of government in the life, liberty, and pursuit of happiness of its citizens intensified in the USA midway in the span of academic urology at University of Michigan. The expanded role affected all aspects of medical practice, education, and research. Countless factors influenced and displayed this change, but two are particularly salient. One milestone was the new national attitude expressed in the Four Freedoms speech of Franklin Roosevelt (January 6, 1941), discussed previously here in Matula Thoughts [Jan 6, 2017 matulathoughts.org]. The Social Security Act of 1965 turned attitude into public policy, immersing government deeply in the healthcare of its people. Although strongly resisted at the time, few can deny that social security is an American core belief. While admittedly imperfect, Veterans Administration and Medicaid funding of healthcare, including skilled nursing facilities for the aged, infirm, and impoverished, provide social security necessary for the stability and ultimate productivity of the country. No rational person who has worked in a VA hospital, Federally Qualified Health Center (FQHC), or nursing home can argue that they are overfunded, although efficiency can always be improved.

Waste occurs in all human activities, it is a natural part of biology. Inefficiencies and mistakes are parts of normal life and learning, our challenge is to attend to them and learn from them. That’s why we inspect the work of our trainees, why we use “lean processes”, why we have morbidity and mortality conferences, why we perform root-cause analyses for errors, and so forth. We pay attention to waste on a daily basis in healthcare, although we could do better, recognizing that local attention to waste by workers in workplaces is the best way to improve products, satisfy customers, and create efficiencies. Centralization of waste reduction, or for that matter centralization of national economies, is a failed experiment amply demonstrated in 20th century authoritarian and communist nations. It also didn’t work so well when authoritarian industries and unions contested for control. Optimal workplaces rely on democratic ideas of liberty and equality, but not in trivial senses. For example, physicians and other health care providers have liberty of free expression like all other citizens, but in their professional roles they are not generally free to bring political or sectarian judgments to patients and their treatment.

America’s commitment to social security, a robust experiment in progress, is threatened. Without a commitment to social security, societies aren’t very nice and don’t look good at the street level, whether rural or urban. Medicaid and the VA provide food, shelter, healthcare, and a measure of security for at least one quarter of the population of the United States, but this massive safety net still misses millions of people, 24 million at the last count I heard. Consider the effect of going back before the Four Freedoms became a national belief, and absent the Social Security Act. The effect on the national economy would be negative, and the mere optics of streets, neighborhoods, cities, and rural communities would reflect an unkind and sad society. The population would be more grossly disparate economically than today and future society would likely be a contest between the lesser nature of mankind’s stone age phenotype against a necessarily Orwellian world.

 

Five.

Hawthorne. This month has its share of notable anniversaries, but one birthday that may not spring to many minds tomorrow, August 5, is that of Henry A. Landsberger, born August 5, 1926 in Dresden, Germany. A Kindertransport refugee at age 12 to England and later a Cornell Ph.D. graduate, this distinguished academic spent his career studying industrial and labor relations. His 1958 article described the “Hawthorne Effect”, the name of a town in Illinois.

The Western Electric factory (below) in Hawthorne conducted a study circa 1930 under sociologist Elton Mayo on the effect of physical environment and work conditions (lighting, rest breaks, work hours, etc.) on worker productivity. Mayo’s group originally concluded that attention to workplace conditions improved productivity, but Landsberger later deduced that it was the novelty of attention that produced higher productivity of the workers. This so-called observer effect, which proved temporary, continues to be debated today, although it is self-evident that the fact of observation is likely to affect performance.

Prior to Hawthorne, simplistic ideas of the ancient “carrot and stick” and the “scientific management” concepts of Frederick Taylor dominated discussions of labor and productivity. Currently, Toyota’s “lean process management” coupled with Daniel Pink’s observation that internal motivation is the best driver of productivity ring true to my experience, harmonize better with democratic societies, and give superior results. Still, the take-away from Hawthorne is that the act of measurement is likely to influence performance and results, in some ways a phenomenon akin to Schrodinger’s cat, in that the act of observation can be consequential to a given reality of the subject.

Whether you are an industrial engineer or an average citizen, there is little doubt of the observer effect relevance. This explains why people get on scales every day, count their steps, time their marathons, measure their RVUs, and test their cholesterol or blood sugar. Measurement matters to the human brain and subtle or gross changes in performance are likely to result. The more you examine something, the more you see in it and the more it changes, at least in your mind and imagination. Schrodinger’s cat, thus, has far more than 9 lives.

Cat

[Not Schrodinger’s]

 

Six.

Universities are society’s best bet for creating a better tomorrow. Medical schools do their part, blending didactics and investigation in rich milieus of clinical practice to produce tomorrow’s physicians, but universities should be challenged to produce a larger part of the spectrum of healthcare workers, training medical assistants and physician assistants, for example, rather than relying on their education from a mix of proprietary schools and other facilities that lack the breadth, depth, and integration of academic medical centers in universities such as ours. A grander vision of health care education nationally would invigorate the medical work force and certain broaden the regional and societal impact of universities.

Few, if any, universities fulfill their educational missions fully. American universities evolved from colleges educating clergymen and civic leaders (Harvard 1636), to institutes training technical professionals (Rensselaer 1824), and research universities (University of Chicago 1890). Modern universities contain schools and colleges plus health systems, research institutes, technology transfer programs, athletic programs, art museums, libraries, performance schools, and a myriad of other things. However, universities need to more fully embrace their roles in educating tomorrow’s global citizens, building tomorrow’s workforces, and generally strengthening human society. As universities fail to step up to the challenge, what other entity in the world can we count on? Surely not “the market.” A controversial book, The Golden Passport: Harvard Business School, the Limits of Capitalism, and the Moral Failure of the MBA Elite by Duff McDonald, takes an iconic business school to task in this regard. Coincidentally I saw a review of this while re-reading Robert McNamara’s book, In Retrospect, wherein he described his experience in the same business school.

“After Berkeley, I attended Harvard Graduate School of Business Administration, soaking up the nuts-and-bolts skills I figured I would need to land a job. Many on the faculty appeared to believe that the purpose of business was solely to make money. But a handful of people, including Ross G. Walker, my financial controls professor and Edmund P. Learned, my marketing professor, took a broader view. They taught that business leaders had a duty to serve society as well as their shareholders, and that a company could drive for profits and at the same time meet social responsibilities. I think of this in a phrase Walker and Learned might have liked: ‘There is no contradiction between a soft heart and a hard head.’ That has been a guiding principle in my life.” [In Retrospect. P. 7]

Economic marketplaces test the principles and character of their workers, and time is the ultimate arbitrator of the testing. Many companies and individuals fail. Certain automobile companies, we have learned, systemically cheated with software programs to produce bogus favorable emissions results during testing or concealed critical safety issues. Health care is not immune to character corruption, with sad examples even in our institution and department, historically. Much like doping in sports, those who get away with cheating may win today, but the long-term consequences of discovery will likely be far more expensive than transient moments of glory, gold medals, or favorable earnings reports. Integrity and character matter. Cheaters steal from the rest of us and civilization is durable only if integrity and reasonable rules are embraced widely.

 

Seven.          

Sectarian vs. secular.  These adjectives, although similar in sound, are antonyms, having opposite meanings. Sectarianism is behavior with ideological, regional, ethnic, partisan, political, or class-based motivation. Naturally everyone has distinct individual identities that reflect these underpinnings, but global citizenship requires that personal sectarianism does not pervert thinking, behavior, and socially-oriented decision-making. Global citizenship may seem an ephemeral idea and impractical aspiration, but the future of seven billion humans inhabiting a single planet depends upon it. Society pays scant attention to the idea of global citizenship in schools, businesses, or politics. Universities attend to this partially, but too lightly. The UN tries to further global citizenship, and some forward-thinking multinational corporations recognize the importance of the idea if there is to be a viable tomorrow for the next generation of humanity, stockholders included. Fitzhugh Mullan in a recent JAMA viewpoint describes how the traditional health professional education has expanded beyond education, research, and clinical care to also include a social mission called “beyond Flexner.” [Mullan. JAMA. 318:122, 2017]

Secularism describes nonsectarian judgment and actions, free of religious, political, ideological, orthodox, or tribal points of view. Secularism is equivalent to cosmopolitanism, that is, world views open to reasoned judgments free of commitments to prior positions, beliefs, or agendas. Secularism is at the heart of the classical liberalism explicit in the Declaration of Independence and the Constitution, with life, liberty, and the pursuit of happiness. The liberty to make judgments and express them freely is the essential basis of a free society. The general security, education, and equality that societies create through government should promote reasoned judgments, creativity, and general prosperity for their people. At least that is the hope of civilization.

 

Eight.            

Further events enhanced the summer. David Watts, gastroenterologist, poet, and performer (above) delivered this year’s masterful Chang Lecture on Art and Medicine, our 11th, called “Love, Words and Medicine.” Ford Auditorium was nearly filled and the spell-binding lecture fulfilled all of our aspirations for an inspiring articulation of the relation of art and medicine (video copy available).

Michael Ost (UM, MD 1993; Ross MBA 2017) from University of Pittsburgh gave a superb Duckett Lecture on pediatric stone disease and Jim Lingeman of Indiana University presented a panoramic view of his innovative findings on the origin of renal calculi in his Lapides Lecture. [Above – Chang Lecture, below – Lingeman & Ost] 

Ost & Lingeman ss

White Coat 2016

The yearly White Coat Ceremony, where entering medical students receive short white coats and stethoscopes, is opening day for the rest of their lives (above: 2016 White Coat). The symbolism of the 2 gifts is strong. White coats signify professionalism, cleanliness, identification, secularism, and protect personal clothes. Stethoscopes are practical tools as well as metaphors for listening. They connect you to patients through physical touch and your attention. After invention in 1816 by Laennec in Paris, the stethoscope replaced the matula as the symbol of medicine. New students taking this first step into their careers share the equivalent of the altruistic gene that has accompanied Homo sapiens from the start. Below: August 1, first day of medical school. M1 groups enjoying a sunny lunch hour outside dean’s Wing.

M1's

The excitement of this moment in time for medical students, may be offset by bewilderment concerning the national healthcare scene. It is a mess, few can deny that. How can politicians, policy experts, bureaucrats, technocrats, theocrats, autocrats, plutocrats, lobbyists, capitalists, or socialists, at democracy’s table build a health system that serves the public well, educates the next generation of health care workers, and advances knowledge and technology efficiently? Clearly, the various sectarian entities are not getting the job done.

 

Nine. 

JW Tour

Tour de Consult. Julian Wan started something remarkable ten years ago. Back then, in those days of competing silos of the hospital-medical school- clinical departments, the hospital financial services data told us that our department averaged only 0.8 consult billings per day. That didn’t seem quite right, because even my small division of pediatric urology seemed to have 1-3 consults on a typical day. The hospital data provided lacked experiential validity, so Julian took it on himself to create a consult database. Navigating some grumbling on the administrative side and inertia of our clinical teams, Julian gained the active engagement of the residents, the key to making the database valid. Julian’s brilliant ploy consisted of making the added work fun and rewarding for the residents by turning it into a game, The Tour de Consult. Now 10 years later we find that our department averages over 8 consults daily.

Tour

[Above: Dr. Wan listing the Double Century Club contenders. Below: Yooni Yi collecting the prize at the end of July M&M Conference.]At the start of the residency training year, chief residents pick teams of colleagues for The Tour and begin a new season. The teams select their own names – this year they are Guardians of the Glomeruli, Luck and Balls, Amir’s Dynasty, and Everything’s Bigger in Texas. Periodically at Grand Rounds Dr. Wan updates everyone on team progress. Faculty are also included in the reporting, but are not on the teams. Final results and awards are presented at the end of the year. Julian himself funds the gifts and won’t take any help or contributions for the iPads and Apple computers he gives the winners. [Above: awards at Grand Rounds] In addition to the ultimate team awards, Julian has created individual awards such as the Century Club (more than 100 consults in a year), Double Century Club, and the new Triple Century Club.

The Tour has turned consults into incremental financial benefit for the department, increased the quality of care due to better attention and documentation of each consult, maximized the educational value of consults by pulling in the faculty more consistently than before, improved our ability to predict on-call coverage for our urology department, and has also turned this “experiment” into academic products, namely scientific papers from the consult data base: Prospective tracking of pediatric urology consults: knowing is half the battle by Emilie Johnson et al (J Urol 187:1844, 2012) and Pediatric urethral catheter consultations: understanding driving factors by Nina Casanova et al (J Urol 191:1396, 2014) are 2 examples.

 

Ten.

Top of Park

Summertime.  This classic song of this season was completed by George Gershwin in February, 1934, as an aria and lullaby for his only opera, Porgy & Bess. Gershwin didn’t get the chance for another opera, as he died of brain cancer (glioblastoma multiforme) 3 years later in July, 1937, at age 38. DuBose Heyward wrote the lyrics, as well as the 1925 novel Porgy, the basis for the opera. Over 25,000 different recordings of Summertime exist [J. Nocera. Variations on an explosive theme. NYT. Jan 21, 2012]. By interesting coincidence, Heyward was a descendant of Thomas Heyward, Jr. a signer of the Declaration of Independence.

Porgy_(novel)

The Ann Arbor Summer Festival is a wonderful community collaboration of city government, the University of Michigan, private businesses, nonprofit organizations, philanthropic donors, volunteers, artists, participants, and children. If you missed it this year, calendar an evening for it in 2018. The kids in blue and red above are those of Associate Professor and VA Chief Ted Skolarus and his wife, Lesli, Associate Professor of Neurology. I encountered them twirling hula hoops in front of Rackham one evening last month. I was surprised to see these hoops back in action. They were popular when I was a kid, although I wasn’t as successful with them as the Skolarus boys. Hoop dancing, an ancient method of Native American storytelling uses hoops made of wood, grasses, bamboo, and vines, but the plastic toy hoop made by Arthur Melin and Richard Knerr (Frisbee inventor) in 1958 was a major success for their Wham-O manufacturing company. Nowadays, people get stories from television, computer screens, or print media and hula hoop spinning persists as just plain summertime fun for kids of all ages. With another month to go, summertime 2017 has been good in Ann Arbor, reminding me often that we can bring art in many forms not just to medicine, but to all of life.

 

Thanks for reading this monthly column of mostly secular thoughts from my perspective in the Department of Urology at the University of Michigan.

 

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