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

Matula Thoughts December 2, 2016

Politics, nutcrackers, and earthly delights
3799 words

One.

election-2016-copy

This has been a year of political surprises with Brexit, the Columbian failure to reconcile with FARC, and the American presidential election. The weekend after our election I happened to be at the Fourth Quinquennial John W. Duckett Festschrift at the Union League of Philadelphia. This venerable institution was founded in 1862 as a patriotic society to support the policies of Abraham Lincoln, whose ideas seem so obvious and mainstream today, but they split the United States nearly permanently at that time. In a Union League reading room you see our friend and colleague George Drach contemplating the meaning of the election for healthcare. Just this past summer George spoke at our Duckett/Lapides Symposium on the implications of the MACRA law, passed earlier this spring with strong bipartisan support. Whether or not the Affordable Care Act (ACA) and MACRA disappear, healthcare policy, regulation, and economics are going to get evermore contentious and confusing. Politics may be easy to distain, but they surround us and shape our lives. This milestone day, December 2, is worth recalling for two examples of politics and ideologies that led nations and people sadly astray.

First example: red scares. The Cold War, following WWII, instilled legitimate anxiety over the spread of communism in the West where scoundrels capitalized on that fear and created the Second Red Scare (1947-57). A First Red Scare (1919) followed WWI and the Bolshevik Revolution of 1917. Both phenomena occurred during times of patriotic intensity and exploited fears of communism. The second scare lasted far longer than the first and came to be known as McCarthyism after its central figure Joseph McCarthy, US Senator from Wisconsin.

herblock1950

[Above: Herblock cartoon March 29, 1950 Washington Post, introducing the term McCarthyism.] Paranoia crossed the United States from Washington to Hollywood and left its effects in Ann Arbor, where 3 faculty members were dismissed by the University for refusing to testify to the House Un-American Activities Committee (HUAC). Mark Nickerson (UMMS Pharmacology), H. Chandler Davis (UM Mathematics), and Clement Markert (UM Biology), suspected of membership in the Communist Party, were called to Lansing on May 10, 1954 to testify before an HUAC sub-committee. The professors refused to answer certain questions, claiming Fifth Amendment privilege, and UM President Harlan Hatcher promptly suspended them pending a faculty inquiry related to “intellectual integrity.” Nickerson was fired out of concern that he was damaging the reputation of the Medical School and University. He went on to a distinguished career in Canada. Davis was also fired and later served jail time for contempt of Congress. Markert was retained but left UM soon thereafter. While this breech of their civil rights passed public muster in the Red Scare fervor, the breech of their tenure rights (Regents bylaw 509) tripped up the university and caused an academic firestorm. The American Association of University Professors would later ask the UM to make “a significant gesture of reconciliation” and that became the annual Davis, Markert, Nickerson Lecture on Academic and Intellectual Freedom. [James Tobin. Seeing Red. Medicine at Michigan Spring, 2009; 11:14-15] That second Red Scare began to wind down later in 1954 on this day, December 2, when the United States Senate voted 65 to 22 to censure McCarthy for “conduct that tends to bring the Senate into dishonor and disrepute.”

castro

Second example: smoke and mirrors. On this day in 1961 Fidel Castro, in a nationally broadcast speech, announced that Cuba would adopt Communism, surprising us in the north and setting off a chain of events with the Cuban Missile Crisis the following year that nearly brought the world to nuclear confrontation. A recent book by former Secretary of Defense William Perry (My Journey at the Nuclear Brink – mentioned here a few months back) offers a frightening account of that time and a more frightening preview of the world ahead of us now. While Castro’s iron grip endured for a half century his ideological experiment failed and he died just 7 days ago. Venezuela under Hugo Chavez tried to reprise the Cuban experiment, but that too didn’t turn out well for its people. Chavez died in 2013 after treatment in Cuba for unspecified malignancy. Both dictators rode waves of populism in their countries, where celebrity ideology support them even to this day, in spite of the economic and social disintegration they left behind, showing once again that populism usually turns out poorly for the populace at the end of the day. [Picture above: Wikipedia]

 

 

Two.

colors

Autumn colors peaked late this year, reaching well into November in Ann Arbor even past election day. After a nontraditional election season the people spoke and the transition of power is following its honorable historical precedents. What this will mean in terms of health care remains to be seen. The ACA will be problematic to unravel and, with it or without it, deployment of fair and excellent health care, the mission of academic medical centers, and the stability of the health care industry are at risk regardless of whatever party dominates the day. Healthcare has been a hard nut to crack in America and a viable menu of choices for its deployment remains elusive.
The University of Michigan urology microcosm, however, seems reasonably in balance. Last month we completed residency application interviews for more than 60 prospective trainees. The four to match here will begin their 5 years of residency in July of 2017 and graduate in 2022. [Above Medical School foliage. Below view from Bank of Ann Arbor headquarters]

baa

Last month was also notable for its super supermoon (below). The moon’s orbit came so close to the earth that it was larger and brighter than any time since January 26, 1948. Having missed it back then, I took the picture below on November 12. To a lesser degree supermoons occur every 14 months when a full moon occurs at its perigee (closest encounter). More periodically the moon’s oval orbit elongates to create the super supermoon effect.

supermoon

Michigan Football’s last home game was an exciting victory over Indiana, bringing the first seasonal snowstorm in the fourth quarter when we also saw snow angels on the field during time outs.

first-quarter

[Above: first quarter. Below: fourth quarter from Sincock suite]

snowy-4th

um-20-iu-10

The season ended a week later with an unprecedented double overtime loss in Columbus.

 

 

Three.
We shouldn’t leave 2016 without mentioning once again, Jheronimus van Aken, the Flemish painter known as Hieronymus Bosch who died 500 years ago. His Garden of Earthly Delights, a triptych in The Prado, depicts strangely imagined hedonistic days of mankind between the Garden of Eden on the viewer’s left and the Last Judgment on the right. Bosch painted the work around 1497, which for historical perspective was five years after Columbus landed on a Bahamian island and claimed the adjacent continent of diverse people, flora, and fauna for the King and Queen of a nation thousands of miles away.

el_jardin_de_las_delicias_de_el_bosco-1

Bosch also painted a strange work called The Wayfarer, mentioned here last month for its stranguria depiction. The world of Hieronymus Bosch around 1500 was probably a pretty grim place, although not devoid of earthly delights, as he imagined in his triptych. A later triptych, The Last Judgement (c. 1527) by another Dutch artist Lucas van Leyden, depicts the actual day of judgment in the middle panel flanked by heaven on the left on hell on the right.

van-leyden

The times of Bosch and van Leyden were framed by fierce religiosity that juxtaposed nations and perpetrated conflicts negating the very values of the religions. Earthly delights, in the minds of those artists and most of their contemporaries, were only a brief interlude before the Heaven and Hell that defined mankind. Native Americans, suffering the European invasion, had no pretension to those ecclesiastical visions of heaven and hell, but rather sought to make the most of their experiential present, albeit with respect to their forefathers and the spirits of their present-day world. It was quite a contrast of civilizations and the Europeans surely brought dimensions of ecclesiastical and actual hell to North America.
Ecclesiastical visions have rightly become personal matters in most of western society. The separation of church and state, as espoused in The Constitution, was a forward step in the self-determination of mankind, although it remains under constant challenge at home and abroad. If The Garden of Earthly Delights is all we can expect in life (before Heaven or Hell) then it should be fair and just, and health care is central to the mix of basic expectations.

 

 

Four.

screen-shot-2016-11-01-at-10-36-49-pm

After viewing van Leyden’s triptych at the Rijksmuseum in Amsterdam early this autumn, while en route to a pediatric urology meeting, I was stopped in my tracks by street musicians playing an enchanting soft tuba staccato note that morphed into the familiar beginning of Vivaldi’s Concerto No. 4, “The Winter.” It hardly felt like winter at the moment, but it was a beautiful interlude. Known as The Red Priest (Il Prete Rosso) Antonio Vivaldi wrote The Four Seasons around 1723 and published it in 1725, coincidentally in Amsterdam. Vivaldi clearly was familiar with the nastiness of freezing rain and treachery of icy paths as seen in the narrative that accompanied his piece (below).

Allegro non molto
To tremble from cold in the icy snow,
In the harsh breath of a horrid wind;
To run, stamping one’s feet every moment,
Our teeth chattering in the extreme cold
Largo
Before the fire to pass peaceful,
Contented days while the rain outside pours down.
Allegro
We tread the icy path slowly and cautiously,
for fear of tripping and falling.
Then turn abruptly, slip, crash on the ground and,
rising, hasten on across the ice lest it cracks up.
We feel the chill north winds course through the home
despite the locked and bolted doors…
this is winter, which nonetheless
brings its own delights.

Winter Solstice will be here soon (December 21) and after that interlude of shortest daylight, each passing day will be a step closer to spring, in spite of “the harsh breath of a horrid wind.”

 

 

Five.
Mirror neurons again. Since I read John Berger’s A Fortunate Man last summer, Dr. John Sassall and his deep empathy for his patients in an impoverished English hamlet have haunted me. The lives of those people in the mid 1960s were perhaps not so far removed those Bosch depicted across the North Sea before the Industrial Revolution. While Sassall may seem hypersensitive, he was not so different from the rest of us but for our lesser imaginations. The journalist’s impressions of Sassall’s thoughts are worth repeating.

“Do his patients deserve the lives they lead, or do they deserve better? Are they what they could be or are they suffering continual diminution? Do they ever have the opportunity to develop the potentialities which he has observed in them at certain moments? Are there not some who secretly wish to live in a sense that is impossible given the conditions of their actual lives? And facing this impossibility do they not then secretly wish to die?” [Berger. A Fortunate Man. p. 133]

lange

[Classic photo of Dorothea Lange. Destitute pea pickers in California – mother of 7. 1936. Library of Congress.]
My daughter Emily, a young English professor at Columbia, teaches Aristotle’s three methods of persuasion: ethos, logos, and pathos. Visual art, Dorothea Lange’s photography for example, captures the suffering that troubled Sassall so greatly and should trouble us too. We are insulated from pathos by the professional boundaries of ethos and the logos of our science, metrics, and computers. The grim thoughts of Sassall stretch the role of a physician. Yet, who in society has a greater mandate to defend mankind’s well-being specifically and generally? Clergymen, teachers, and rare politicians share this charge, but day-in and day-out, healthcare providers are most consistently on the front lines with some of the best tools to ameliorate the daily pains and continual diminutions of individuals around us. Urologists and other specialists may claim turf protection, but can’t forget that they are physicians first and foremost. Berger’s last sentence was most likely targeted to the difficult days at end-of-life, the time when the garden of earthly delights has run out – familiar terrain for most urologists.
The toll of pathos was considered by Jennifer Best, from the University of Washington in Seattle in A Piece of My Mind column in JAMA called The Things We Have Lost [JAMA 316:1871, 2016].

“When most people consider the grief endured by physicians in training, they look first to the devastating narratives of patient care – sudden illness, agonizing decline, putrid decay, untimely death, haunting errors, and crushing uncertainty. Even more than a decade from residency, I am pierced by these tragic moments and faces – each still heart-shatteringly vivid.”

Best goes on from this opening statement to suggest not only confronting these griefs in “curricular endeavors” such rounds or narrative sessions with trainees, but also considering personal losses as we play out our roles in what she calls physicianship. Her claim is that when we accept the role of healthcare provider, we step into a new identity and lose some of our freer, ad lib, selves. Growing our sense of empathy, yet maintaining resilience is the challenge. Best rejects counter arguments that her considerations are “first-world problems” or that because “it could be so much worse” we need not be overly concerned with professional fragility. Her column offers a good footnote to A Fortunate Man.

 

 

Six.
Department of complaints. We spoke last autumn at some length on medical error and argued that our profession can never be free from it. Error is a fundamental property of life and intrinsic to all its processes. We study error in healthcare to minimize it and fortunately most error is nonlethal, although even when trivial it can hurt. The University of Michigan Health System, like any large scale enterprise, has many processes susceptible to error. With 2 million ambulatory care visits and 50,000 major surgical procedures yearly countless opportunities arise for untoward events ranging from missed blood draws to serious complications in ICUs. Every complaint is a gift, of a sort, providing opportunity for improvements in individual actions, processes, and structures. I recently heard complaints that targeted team leadership factors and the “hotel” functions of hospitalization.
Complaint A. Who is my doctor? Patients generally are thankful about their care from the doctors, nurses, and other members of the team, however fumbled handoffs or inability to identify the responsible member of a healthcare team on any given day are vexing. You can find analogies for this in baseball or air travel industries where the buck stops with the general manager of the team or the pilot. Both endeavors, like health care, require complicated teams, but each fan or traveler can usually identify who is in charge. Health care teams and systems need to make their ladders of responsibility more visible.
Complaint B. Must I share a room? Double room occupancy at UM Main Hospital is a vestige of an older era of health care, but is no longer acceptable for a variety of reasons including privacy, infection control, safety, comfort, and patient satisfaction. Our failure to convert the remaining double rooms over the past 20 years is an embarrassment today and correction is in the works, but  it’s nearly a billion-dollar fix including a new patient tower estimated to open in 2021.

 

 

Seven.
MACRAnyms. Acronyms abound in most occupations and populate the shop talk that distinguishes workers from the public at large. The big acronym for health care in 2017 is MACRA – the Medicare Access and CHIP Reauthorization Act of 2015. Sponsored by Congressional Representative Michael Burgess (R-TX-26) this act removes the sustainable growth rate methodology for the determination of physician payments and extends aspects of Medicare and the State Children’s Health Insurance Program (CHIP). I can’t pretend to understand this large and complex set of regulations outside of a few salient details, but fortunately we have experts among us at Michigan such as Tim Peterson (below – Medical Director Population Health Office UMMG). Like many well-intended public policies, unintended consequences are inevitable in MACRA, so the better we educate ourselves the more capable we will be to help patients lost in the regulatory shuffle and the greater likelihood we will have to protect the mission and values of healthcare education, clinical delivery, and research.

peterson-tim

 

MACRA attempts to displace the dominant model of physician payment from fee for service (FFS) to payment for value. While it is fashionable to vilify the motivational factors of FFS as a driver of health care expenses (and presumably unnecessary services) there is risk in terms of motivating the restraint of healthcare services. I also recognize a healthcare safety net is direct of a civilized society; universal access to health care is in the national interest. I equally recognize the downside of a system that does not reward work in terms of time and quality.
The intent of MACRA in shifting payment from FFS to payment for quality and value, set by complex government formulas, is an unproven experiment. Market forces should largely determine value and quality, while professional organizations should set basic standards for services. National healthcare cannot be left exclusively to the invisible hand of the market or the heavy hand of government. Healthcare affects everyone, employs one in six people in this country, and is a huge piece of our economy. The present systems of healthcare (there is no single “system”) need huge improvement, but changing it on a massive scale can be dangerously disruptive.
We need various systems of healthcare in simultaneous play, from the private and the public sectors to provide equity, excellence, innovation, and value. The private sector can best supply competition, value, innovation, and stakeholder responsiveness. The public system can best supply the safety net, equity, rules, education, and research. No single system, set of laws, organization, or paradigm can do it alone and we must be suspicious of any grand “answer,” for healthcare is a very hard nut to crack.

 

 

Eight.

nutcrackercollection
The nutcracker comes to mind at this time of year – not for the compression of urologic structures by the superior mesenteric artery and aorta, but for the ballet based on ETA Hoffmann’s story in 1816, Nutcracker and Mouse King. [Above: Nutcracker collection. Wikimedia Commons] The original story featured a nutcracker whose jaw was broken by an unusually hard nut, triggering political intrigue, revenge, hate, battle, and murder. Alexandre Dumas in 1844 lightened and popularized the story as The Tale of the Nutcracker, that became the basis for Tchaikovsky’s ballet in 1892. It is a rare American community in December where you can’t find an amateur or professional version to attend. You can read a synopsis of the morbid original story in Wikipedia (and perhaps give a modest annual contribution to keep that great public good afloat).
Our own great cardiologist, Kim Eagle, years back as editor of the NEJM section Images in Clinical Medicine, published a classic image of a 52 year-old woman with mild episodic gross hematuria from renal vein compression by the superior mesenteric artery. [Kimura & Araki. NEJM. 335:171, 1996] Improved CT technology offers a better image (below) in a more recent paper from the Mayo Clinic Proceedings. [Kurklinsky & Rooke. Mayo Clinic Proceedings 85:552, 2010]

nutcracker

[Computed tomographic venogram: nutcracker phenomenon.
Distended left renal vein (black arrow) compressed between
aorta and superior mesenteric artery.]

 

 

Nine.
Nutcracker politics continue to play out in life and art. The innovative House of Cards on Netflix is a very dark modern political nutcracker story. People need politics, crave leadership, and tolerate a fair amount of nut cracking.

house-of-cards

Ideology and celebrity can hijack brains like zombie viruses resulting in political choices and actions that prove contradictory to an individual’s ultimate interests. Politics, a term derived from the Greek “of citizens”, is the process of decision-making and governance of stakeholders. Political systems are frameworks that define acceptable political methods in a given society. Confucius, Plato, Aristotle and countless other thinkers have advanced political thought throughout the history of mankind. Formal politics prescribe public elections, national healthcare policy, and self-government as in our UM Health System. Informal politics are at play in all human activities, real and fictional, even as portrayed in The Nutcracker or House of Cards, where acceptable political methods get conveniently perverted to attain political power.

Politics, whether played fairly or unfairly, are essential to operationalize democracy, which is more of a biologic phenomenon, perhaps akin to quorum sensing, than an ideology or mere political system. This amazing universe of possibilities has arisen from 23 pairs of human chromosomes, their 3 billion base pairs, and 21,000 genes. Civilization is a house of chromosomes.

 

 

Ten.
Political parties developed to create candidates for public elections since the days of our first and last politically independent president, George Washington. Our present bivalent political system dates from 1854 when the USA has had two main parties, the then-dominant Democratic Party and an upstart party of anti-slavery activists, modernizers, ex-Whigs, and ex-Free Soldiers. The upstarts coalesced into a Republican Party that held its first official convention in Jackson, Michigan July 6, 1854. Within 4 years Republicans dominated all northern states and in 1860 they won control of both houses and their candidate Abraham Lincoln was elected president. He had a tough presidency and many expected little of him, but Lincoln rose to the occasion of the office and the issues of the day. Two years into his single term, the Union League of Philadelphia was founded. One room (below) features portraits of every Republican president of the United States.

repub-pres

Democratic and Republican parties dominated the American political landscape since Lincoln’s time, while other parties have failed to gain leverage. The Constitution, Green, Libertarian, and other small parties continue to field candidates but attract only small numbers of followers. Candidates for office independent of political party are not uncommon in local elections, but rare in higher office. Washington was the last independent president. Bernie Sanders is the longest serving independent in the history of the US Congress, although he aligns with Democrats. The Socialist Party of America, founded in 1901, never produced much of a winning ticket and dissolved in 1972. The Communist Party USA founded in 1919 was closely tied to the US labor movement, but never gained enough foothold to even have warranted the Red Scares; examples of its failed experiments near to us and in distant nations have dispelled serious interest in modern literate nations.
The 2016 election is over. Democrats will need to reconcile with Republicans and vice versa. The voting closely split the country and each party needs to learn from the other. More importantly both parties need to govern effectively, wisely, cooperatively, and justly. Health care policy is a muddle in the middle of things. Ultimately, though, what really matters above all is financial world-market stability and geopolitical stability. Without these, little else remains, so as with every president – we hope for the best.

political-promises-copy

[A cautionary slogan for politicians: Glen Arbor Fourth of July Parade, 2012 – Decker’s septic pumping truck with slogan: “another truckload of political promises.”]

 

Thanks for reading Matula Thoughts this first Friday in December, 2016 – and best holiday wishes.

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

Matula Thoughts May 6, 2016

DAB What’s New May 6, 2016

Matula Thoughts Logo2

(3948 words)

 

Carl

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

 

 

One.           May, at last.

May 2015

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

 

 

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

 

 

Three.           UMMS graduation.

Cropsey copy

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

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

UMHS

[UM Health System 2016]

 

 

Four.           Role models.

JOW & MJ

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

MR

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

Family Doc

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

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

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

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

 

 

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

Stutzman, DAB, McLeod

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

 

 

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

 

 

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

 

 

Eight.           Harvey & hearts.

Screen Shot 2016-04-26 at 4.28.40 PM

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

Screen Shot 2016-04-26 at 4.32.15 PM

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

 

 

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

Baylor fac & DAB

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

Res Conf


Boone & Bloom

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

Roth & Miles


Chester

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

Residents dinner

[Below: Michael DeBakey, museum photo]

220px-Michael_DeBakey

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

 

 

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

Bradford, Carol

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

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

Matula Thoughts September 4, 2015

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

 

Matula Thoughts Logo1

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

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

3914 words

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

Screen Shot 2015-08-29 at 11.51.55 AM

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

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

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

 

3.    Sept Heures

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

 Feb 1848

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

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

Napoleon III

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

 

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

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

EMU AAUP

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

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

Sutton RI

[Sutton RI, The No Asshole Rule. 2007 ]

 

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

 

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

John Quincy Adams

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

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

 Deweytruman12

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

 

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

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

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

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

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

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

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

Retreat

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

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

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

 

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

 

9.    Shinola

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

 Rick

 

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

 Runge, Johnson

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

 

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

David A. Bloom

 

Matula Thoughts August 7, 2015

Fair weather, formicidae, fables, and funambulism

3415 words

 

 1.   Brehm

August in Ann Arbor with long days of sunlight, warm breezes, and summer clothing is especially sweet by contrast to our winter days. Thanks to generous rains filling our rivers and refreshing the ground water Ann Arbor’s August is immersed in green. [Above: view from the roof of the Brehm Tower of Kellogg Eye Center. Below: kayaks by the Huron]

Kayaks

Birds, cicadas, tree frogs, and lightning bugs create accidental symphonies of sound and light in my neighborhood. Summertime in the Northern Hemisphere brings a measure of balance, relaxation, and sunny public spaces. Vacation allows time to recharge and summer in Ann Arbor is pretty much as good as it gets for doing that.

Golf

[Michigan Stadium from Ann Arbor Golf Outing]

August in parts of Europe is almost entirely set aside as vacation time for many workers, whereas in North America “work-life balance” is stricter with a week or two of vacation, plus the long weekends of Memorial Day, Fourth of July, and Labor Day. These thoughts remind me of an animated cartoon that I loved as a kid called the Grasshopper and the Ants, an ancient fable of Aesop recast by a young Walt Disney in 1934 in The Silly Symphony (you can find it on YouTube – it runs 8 minutes).

220px-The_Grasshopper_and_the_Ants

The gist of the story was that a grasshopper had fun and played all summer, while the neighboring ants aligned industriously to work throughout the sunny days storing up food and preparing for winter. When winter came, the cold and hungry grasshopper realized his sorry situation and came begging to the ants for food and shelter. According to Disney’s version, after a momentary reprimand the ants kindly took in the pitiful grasshopper who then entertained them with his fiddle over the winter. In the Aesopian corpus this story is The Cicada and the Ant (classified as Perry 373). The simplistic moral to the story is a useful lesson for children, but humans, unlike ants, need vacations; motivations in the human sphere differ from those in ant land.

 

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[EOW by DAB 2002]  

Ants and humans, E.O. Wilson teaches us, are among the very rare eusocial species on Earth. These colonial animals live in multi-generational groups where most individuals cooperate to advance the public good and to perpetuate the species into the next generation. In effect, their colonies are superorganisms that transcend  individual biologic lives and create civilizations turned over to successive generations. The meaning of individual lives, then, is simply to be found in their contribution to their tomorrow and the tomorrows of their successors. Ants accomplish this work by communicating via pheromones, chemical signals that Wilson and his collaborators elucidated. Pheromones, added to genetic and epigenetic capabilities, vastly enhance the ability of eusocial organisms to deal with and transmit information. The human luck of spoken and written language allows us to process information (sensory, narrative, and numeric), work cooperatively, and create new information that we deploy and pass along to successive generations. The cultural and scientific ways of thinking that emerged from language have produced creativity that has changed the Earth. Whereas internal motivation and environmental pressures inspire personal creativity, it is largely personal and political freedom that allows its dissemination, thereby expanding civilization intellectually and materially.

Tai Che 2

It is a beautiful thing to see people acting in harmonious synchrony. This picture I took outside the de Young Museum in San Francisco this spring shows a display of T’ai chi (太極拳), a Chinese martial art practiced for its health effects, focusing the mind for mental calm and clarity. No pheromones or visible rewards motivate this alignment, the motivation is internal. T’ai chi is lovely to watch, the harmony and synchrony registering pleasurably in the hardwiring of our brains. This is the stuff of art, the deliberate work of other people that we admire and that sometimes astonishes us. You can find beauty in a myriad of other aligned performances. The Stanley Cup playoffs are one example of exquisite and harmonious alignment of teams. Surgical procedures may fall into this realm; it’s interesting that in Great Britain the operating room is referred to as the surgical theatre. When synchrony is harshly enforced, however, as in the dark vision of industrialism depicted by the Diego Rivera murals in Detroit or the failed experiments of communism, alignment is not so pretty. 

 

3.  Diego Rivera

The cartoonish stereotype of disheartened industrial assembly line workers in the Rivera murals has been reinforced by generations of business schools and accounting management ideology. The belief was that managers should determine work-flow methodology and set production targets as if assembly lines were machines to be sped up or slowed down as managers deemed necessary. This is the essence of accounting-based management. The Toyota Process System, now embraced world-wide by forward-looking businesses as lean process methodology, turns this paradigm around, having shown that where workers are empowered to think, innovate, and take pride in their work, better products, greater efficiency, and customer satisfaction will result. Ironically, Toyota’s innovation was initiated over 60 years ago when the company’s founder visited Ford’s massive River Rouge plant just as Japan was rebuilding its industrial base after WWII. Where the American managers saw one thing in the Ford assembly line, the Japanese leaders saw something completely different. The following quote explaining “What Toyota saw at the Rouge” comes from an excellent book called Profit Beyond Measure, by H. Thomas Johnson and Anders Bröms: “When Eiji Toyoda told Philip Caldwell that Toyota had discovered the secret to success at the Rouge, his comment implied that what Toyota had perceived about operations at the Rouge was very different than what Caldwell and his Ford colleagues or their counterparts in the other Big Three auto companies had seen. For one thing, it seems that Toyota people did not view low cost at the Rouge in terms of its scale, its throughput, or its managers’ effort to impose external targets for speed and cost on workers in the plant. Instead, they seemed to perceive a holistic pattern permeating every minute particular of the system. On one level, the pattern that caught Toyota’s attention was the overall continuous flow of work in the Rouge as a whole. But at a much deeper level, they observed that work flowed continuously through each part of the system – literally through each individual work station – at the same rate that finished units flowed off the line.” (Caldwell was President of Ford at the time.) Toyoda saw an organic self-learning system in the assembly line, where expertise at work stations is continuously harvested by motivated workers to improve work flow and product. Jeanne Kin and Jack Billi floated this book to my attention a few years ago and it continues to strongly impact my view of organizational systems.

 

4.   Just as modern industry is embracing the concepts of Toyota Lean Processes, health care systems in their frenzy to cut costs while complying with increasingly onerous regulation are oddly embracing the failed experiments of management accounting that impose cost and throughput targets on health care providers. Data (numeric information) should inform decisions whenever possible, but it cannot be the sole driver of key operational choices. All data must be viewed as suspect for, after all, the numeric information we produce for ourselves is merely an artifact of human invention: numbers and their manipulation may or may not reflect reality accurately. Intense focus on data tends to obliterate stories (narrative information). Truth is elusive and while stories can be just as false or misleading as data can be wrong or misinterpreted, when stories resonate with truth, prove to be genuine, or otherwise offer value they get repeated and stick around. While the accounting mentality examines data for consistency and at its best extracts useful stories from data, the scientific mentality examines and hypothesizes stories and then seeks data to support the story and create a better one. Accounting is a matter of numbers, but science is ultimately a matter of stories. The human brain is hard-wired to relate to meaningful stories, and those ancient ones that endure, such as The Iliad, The Odyssey, and the Bible, endure because they give artful evidence of larger truths, exemplary behavior, or experiences that we keep repeating. Some stories are extremely succinct, but have enough truth that we keep repeating them like: Pythagoras’s story that for a right-sided triangle the area of the square on the side opposite the right angle equals the sum of the areas of the squares of the other two sides. Another durable story is that the area within a circle is its radius squared times an irrational number called pi.One might argue that by its very substance this story is irrational, but it sure seems to have held up through time. A newer story tells of the ultimate connection of light, matter, and energy, that is, is e=mc2. These stories seem to be true and have found their Darwinian niche in the human narrative.

 

5.   We are indoctrinated by stories since childhood. Fables, short stories with moral lessons, typically feature animals with human qualities. Aesop, supposedly a slave in ancient Greece (620-560 BC) a generation after Pythagoras and a century prior to Hippocrates, is the fabulist best known in the Western world. It is an astonishing demonstration of Darwinian durability that his fables have been repeated to children in most languages for well over 2500 years. Ben Perry, the 20th century authority on Aesop, indexed and edited Aesop’s stories for the Loeb Classical Library in 1952. One of the half dozen fables dealing with health care is The Old Woman and the Thieving Physician. This may have been added to the Aesop corpus rather than an original of the actual fabulist. The tale involves an elderly lady with sore eyes who asks a physician to cure her from anticipated blindness, but her deal was that payment had to await cure. The doctor made repeated house calls to apply salves and with each visit stole anything he could take away from the house. Once the cure was competed the woman refused payment saying that her sight seemed to be worse than ever since she now couldn’t see or find any of her household property. This characterization of the dishonest physician was number 57 of the Perry Index.

 

6.   Ben Perry was born in 1852 in Fayette Ohio and received his B.A. in 1915 from the University of Michigan and a Ph.D from Princeton in 1919. His early academic posts took him to Urbana Ohio University, Dartmouth, Western Reserve, and then, for the bulk of his career from 1924-1960 at the University of Illinois. He returned to Michigan as visiting professor in 1967 and died back in Urbana, Illinois in 1968. Perry concentrated his work in two minor genres, the fable and the ancient novel. The Perry Index includes all fables related to, ascribed to, or connected to Aesop and goes from #1 The Eagle and the Fox to #584The River-fish and the Sea-fish.  In addition, the Extended Perry Index goes from #585 Sick Lion, Fox and Bear to #725 Fish from Frying Pan into Coals. Curiously Aesop offered tales of all sorts of creatures and many occupations, but only the occasional doctor’s story in addition to the ophthalmologic case: #7 Cat as Physician and the Hens,  #114 The Physician at the Funeral, # 170 Physician and Sick Man,  #187 The Wolf as Physician, or #289 The Frog Physician, and #317The Unskilled Physician. Some of these were matters of impersonations while others like #57 above were character studies of the profession. Perry #427 was the classic Fox and Hedgehog story, resurrected for our time by Isaiah Berlin.

 

7.   The Art Fair is a special time in Ann Arbor. I lived here for about 10 years before I ever walked around in it – summertime is busy for those who take care of children, pediatric urologists included. In 1997 we started the John Duckett Lecture in Pediatric Urology, in honor of a colleague and a friend of Michigan Urology who had passed away that year. The idea was that this would take place on the Friday morning of the Art Fair, and we would close up most of our clinical and research work for the day. Our staff would simultaneously have Staff Education Day in the morning and the afternoon free for the Art Fair or whatever, as their annual birthday present. Over the years we have expanded the intellectual part of our Art Fair week with the Chang Lecture on Art and Medicine Chang on the Thursday and usually added a Lapides Lecture to the Friday session. This year we asked one person, Pierre Mouriquand from Lyon France, to do both the Chang and Duckett Lectures. In effect this was asking Pierre to walk a tightrope between two intellectual towers, and he navigated the line beautifully.  As a great pediatric urologist and a painter of substance and daily practice, he is well qualified on both fronts. The Chang Lecture consisted of Pierre’s story Slowly down the Rhône: the River and its Artists. He produced a magnificent talk bringing together not only art and medicine, but also geography.

Screen Shot 2015-07-20 at 7.40.50 AM

His Duckett Lecture was Understanding the Growth of the Genital Tubercle: Why it is relevant for the Hypospadiologist.  Here he showed his mastery of the field with a brilliant update on embryology and challenging thoughts on surgical reconstruction of difficult dysfunctional anatomy. He fielded a series of case presentations from residents and later in the day attended our Disorders of Sex Development (DSD) team meeting and lunch, where he challenged the modern terminology and presented some videos that showed new concepts in reconstruction. In the evening at dinner our residents and the pediatric urology team got to know Pierre and his wife Jessica mixing technical talk, health systems discussions, and seeing how a couple successfully navigates the challenging world of life, family, and academic medicine. 

Pierre & Jessica

Regarding this first academic event of the new season of residency training (also called Graduate Medical Education or GME) I need to invoke a sports metaphor and say that “Pierre hit it out of the park.” Events like these fulfill the essential duty of the university: sharpening inquisitiveness, disseminating ideas, widening cosmopolitanism, and educating our successors.

 

8.   Chang Lecture on Art and Medicine 2016. Our speaker next year will be Don Nakayama, former chair of the Surgery Department at West Virginia. He wrote an interesting article in Pharos last year on the Diego Rivera murals at the Detroit Institute of Arts. [The Pharos 77: 8, 2014] Perceptively, he recognized that the so-called Surgery Panel on the South Wall was not a depiction of “brain surgery” as art historians have claimed, but rather an illustration of an orchiectomy, a procedure much more attuned to Rivera’s view of the Rouge Plant workers. It is a great testimony to the vision of Edsel Ford to have brought Rivera, arguably the world’s best muralist of the time and an ardent communist, to Detroit to produce the work in 1932. Things didn’t go so well later in New York City when Rivera tried to repeat the experiment with the Rockefellers, but that’s another story.

Orch

[Lower right mural on the South Wall: the orchiectomy]

Caleb Nelson will be doing the Duckett Lecture and Bart Grossman will be doing the Lapides Lecture next year for an all-Nesbit Line up on that Friday of the 2016 Art Fair.

 

9.   Little Red Hen  Disney’s Silly Symphonies also included The Wise Little Hen, a version of a Russian folk tale more popularly known as The Little Red Hen. The nugget of the story was that the hen finds a grain of wheat and asks the other animals on the farm to help plant, grow, and harvest it. None chose to help, but after she harvests the wheat she asks again for help threshing, milling, and baking, but none step forward. After the bread is done, she asks who should help eat it – and of course everybody volunteers. The hen, however, says sorry “if any would not work, neither should he eat.” (The Wise Little Hen  included the debut of Donald Duck.) President Ronald Reagan referred to this story in 1976, citing a politicized version  in which the farmer chastised the hen for being unfair. After the hen was forced to share her bread, she lost the incentive to work and the entire barnyard suffered. This twist on the story made it a cautionary tale slamming the welfare state. While the story teaches children the importance of doing their part in terms of the daily work of the community it lacks the complexity of reality. Modern society is far more complicated than a barnyard and the line between personal responsibility and public beneficence (i.e. government) is tricky to arbitrate. Furthermore, many in society experience tragic bad luck beyond their control or are unable to assume personal responsibility. Reagan’s farmer had the un-antlike characteristic of compassion, a human quality that must have long-preceded even our biblical days. A society has to nurture personal freedom, creativity, and individual responsibility if it is to be successful, but without kindness and compassion a civilization is not a human one. After all, when Disney anthropomorphized his ants he gave them not just language, but also compassion.

Where do we draw the lines regarding personal freedom and such things as immunization mandates, smoking, drug use, obesity, and dangerous behavior? Should motorcyclists have to wear helmets? How do we provide health care to the indigent and incapable? How do we create health care equality and affordability? These questions ultimately get arbitrated in the political arenas regionally and nationally, generation after generation. Our nation walks on a tightrope between the cartoonish ideologies of the welfare state and what some might call individualism, capturing the beliefs of libertarianism, laissez-faire capitalism, and ethical egoism. Obviously neither the welfare state nor any “ism” has it right – the best path for a just, creative, and cosmopolitan civilization is a path in between the cartoons. The bad news of today (and maybe this is the bad news for every human era) is that cartoonish people find their ways to leadership and compel the rest of us along irrational paths that threaten  the future we want to turn over to our next generation. All citizens need to step up their understanding of the issues of public policy and health care as well as involving themselves in its regional and national discussions. We can no longer let politicians, accountants, and pundits alone shape the critical decisions.

 

10.  Funambulism. On this day, August 7, in 1974 a 24-year old Frenchman named Philippe Petit walked across a high wire he had rigged between the Twin Towers of the World Trade Center. He actually crossed the wire 8 times, performing for 45 minutes to the amazement of on-lookers in the towers. He must have looked like an  ant to those on the ground, and vice versa. Petit’s funambulism represents a perfection of self-alignment in terms of balance that few can achieve, yet it is also an astonishing display of self-confidence, clandestine preparation, and admirable civil-disobedience. Curiously funambulism defines tightrope walking and a show of mental agility interchangeably. Few can deny that serious tightrope walking is as much a matter of mental as physical agility and you have to admire the internal drive that motivated Petit to accomplish this heroic feat. That was art.

Pettit

Postscript: With the start of August we saw the retirement of Jack Cichon, our departmental administrator, and Malissa Eversole is now steadily in place on the job. Jack managed the business and operational affairs of Michigan Urology for 20 years with great loyalty, integrity, and (at some challenging times) extraordinary courage under pressure. He becomes an honorary member of the Nesbit Society and we hope to continue to see him in the course of our departmental events, noting his broadened smile of relief from the administrative pressures of the University of Michigan Medical School and Health System that he served so admirably.   

Cichon 2015

Thanks for spending time with What’s New and Matula Thoughts.

David A. Bloom, MD

Department of Urology, University of Michigan Medical School

Ann Arbor

 

Matula Thoughts May 1, 2015

 

Matula Thoughts May 1, 2015

2992 words

 

Some recent readers of these essays, Matula Thoughts, have asked what it’s all about. For a little more than 15 years I’ve been putting out a mixed bag of observations as a monthly e-mail communication, initially to the entire medical school faculty when I worked in the dean’s office of Allen Lichter. We called the communication What’s New, and I kept it going (expanded to a weekly email) after my fulltime return to the Urology Department. Currently, on most weeks What’s New is written by members of our department under Associate Chair John Wei as the primary author/editor, leaving me only with the monthly “first Friday” issue covering topics as diverse as Hippocrates, astronomy, healthcare, urology, etc. A little over two years ago, we spliced the first Friday issue to a parallel version on a blog called matulathoughts.org, explaining the title in an introductory piece on March 26, 2013. If you missed the explanation you can find it added to this communication as a post-script.

 

 MH 26392)

 

1.           MonetMay’s long stretches of daily sunlight, entices us that summer is just around the corner. Claude Monet’s painting Woman in a Garden of 1867  (at the Hermitage Museum in St. Petersburg) shows one of those days that we’ve longed for throughout this long winter. A brush of snow last week challenged us briefly, but today the buds are on the trees, songbirds are in the air, and the hosta poked out of the ground for a few days until our local deer chomped them down. In May we drive home from work when it is still light outside. Whereas the USA celebrates Labor Day in the autumn, for most other nations May 1 is International Workers’ Day, an event that began around this time of year to honor workers according to an archaic view of the working class.  

Int Workers Day  [Source: Wikipedia.  Dark blue = Labor Day on May 1, Light blue = another public holiday on May 1, Pink = Labor Day on another date, Red = No Labor Day]

Yet, well before those early public celebrations of the working class, Adam Smith and other thinkers were keenly aware of the division of labor, on which society depends so totally, into many specific jobs, trades, crafts, and formalized professions. Professions maintain standards of practice and systems of education, and the medical profession is one of the oldest. May happens to be a traditional time for medical school graduation, a lovely ceremony marking the emergence of a new cohort of MDs. When the first class of medical students graduated in Ann Arbor in the mid-19th century they were deemed ready to enter the workplace as new doctors after 2 years of lectures that comprised their professional education. Since then medical school has grown to 4 years of study that also includes laboratory investigation, self-study, and clinical experience. Graduation, an esoteric labor day of a sort, now marks a transition to the career-defining stage of medical education, namely residency training, a phase lasting an additional 4-10 years. Many medical schools, including ours at the University of Michigan, include recitation of the Hippocratic Oath at graduation to connect the graduates, as well as the established physicians present, to the ancient and durable principles of their profession.

Hippocrates  Screen Shot 2015-04-29 at 3.59.14 PM

[Left: Hippocrates’ statue at UM. Right: UMMS graduates in 2013 who entered urology programs. Now, nearly PGY3s, they are halfway through residency. Sarah Hecht now at Portland, Nirmish Singla in Dallas, Adam Gadzinski in San Francisco, and John Delancey in Chicago at Northwestern]

 

2.          This May is also noteworthy for the AUA Annual meeting when our faculty and residents present their work in the intellectual marketplace of international urology. Michigan urology usually has well over 100 podium presentations, posters, and other prime time appearances. The national meeting is the place to hear new ideas, discover new technologies, extend our reputation, spot new talent for recruiting, as well as reconnect with our own alumni and friends. Sunday’s Reed Nesbit Reception hosts well over 100 of our alumni and friends annually, and we will report on this next month. What does the Hippocratic oath have in common with the AUA? Both are manifestations of professionalism, the medical arts at large and urology in particular. Professions have a long record throughout human history, the medical ones going back to healer-priests, the Hippocratic School, and the Company of Barber-Surgeons as examples. In professions societies recognize the specialized knowledge of groups of individuals and accords them rights to practice, educate themselves, set standards, and innovate. These rights are conveyed in the interest of the public. It’s hard to imagine how government or the business world could perform these functions as well and as efficiently as do the professions in this day and age with 150 areas of medical and surgical areas of expertise, to say nothing of dentistry, pharmacy, nursing, podiatry, much less all the many other professions in the complex tree of knowledge. There is no free lunch, however, and the cost for these freedoms is a social contract in which the professions must look out for the public interest if they are to maintain the public’s trust.

 

3.          The invisible hand that seems to maintain the efficient function of society is a useful metaphor that traces back to Adam Smith, if not before him. Some of that mysterious force is Darwinian and this is discussed nicely by David Sloan Wilson in a new book, Does Altruism Exist? Culture, Genes, and the Welfare of Others. He wrote: Group-level functional organization evolves primarily by natural selection between groups. This would explain evolution of the functional behavior of termite civilizations, bee colonies, and human society. The principle guiding hand in human society is hardly invisible and that is the hand of the ruling priest, king, or governing agency that sets laws and regulations to determine how people behave and how business enterprises work. A second factor, in addition to the regulatory laws, is at play in the commercial world and this is Adam Smith’s invisible guiding hand. Somehow the commercial world markets, largely and efficiently, regulate themselves. A third guiding hand comes from the professions, work groups that transcend mere jobs, to create cultures that set standards for their work, educate their successors, and fulfill expectations of the public. The profession of medicine has served human society from its earliest days and the Hippocratic Oath, dating back nearly 2500 years, is evidence of how a self-ordained profession can define its scope of work, declare its values, and pledge a set of behaviors in service to the public. Other professions have followed this model of an oath, although the Hippocratic remains the most durable and popular prototype.  

 

4.          Kipling a  Rudyard Kipling is well known for stories and poetry, but I was surprised to learn he authored the Ritual of the Calling of an Engineer and that it was first recited as an oath at the University of Toronto 90 years ago today. The idea came from professor H.E.T. Haultain of that university, who believed graduating engineers should have an ethical framework. The Quebec Bridge disasters were a motivating factor and Haultain, on behalf of the Engineering Institute of Canada, persuaded Kipling to write the words. Other professions also grapple with ethical responsibilities. The American Institute of Architects recently considered a petition to consider whether its members should be censured for designing solitary-confinement cells or death chambers. An article by Michael Kimmelman considered the ethical issue of humane prison design: “What are the ethical boundaries for architecture? Architecture is one of the learned professions, like medicine or law. It requires a license, giving architects a monopoly over their practices, in return to a minimal promise that buildings won’t fall down.”  [NYT. Critic’s Notebook. Feb 17, 2015. C1] The Institute rejected the petition, but the implication was clear that many members of the profession believe that the public deserves more than that minimalist promise of product stability. Codes of ethics and rituals bind people of like skills and interests together. Most professions derive their main value and meaning in relation to public service. It seems to be noble and virtuous for a profession to articulate and perpetuate its values and standards of service to the public. Ultimately, the professions exist at the pleasure of the public. When the public loses faith in the public service of a profession, that profession becomes just another business and a commodity. [Rudyard Kipling by Philip Burne-Jones. 1899. The Granger Collection NY. Public domain]

 

5.          Scale.  Our Department of Urology has reached a considerable size. When I joined the Section of Urology of the Department of Surgery, as it then was in 1984, I was the 6th faculty member and the only pediatric urologist. Now we have 5 pediatric urologists and a total of 37 regular faculty and 15 joint faculty shared with other departments. People ask: isn’t that too large a department? Or, how big should we be? The matter of size is important mainly from the point of understanding our mission and being able to execute it excellently. Our mission has three parts: education, research, and clinical care. However, from the mission derives our essential deliverable: kind and excellent patient-centered care, thoroughly integrated with education and innovation at all levels. This essential deliverable is both the milieu for deployment of our mission and our moral epicenter.

 

6.          From the educational perspective, an excellent urology department needs to deliver great urologic care in all facets of urology. To teach urology a team of faculty needs to be engaged in urologic practice. This requires a certain depth of faculty, that is a redundancy of personnel to manage complex and routine urologic conditions around the clock. For some subspecialties in urology, such as andrology, two faculty members may permit ample coverage, whereas in other areas a larger number is necessary. For example, we hope to establish a program to provide 24/7 urinary tract stone coverage, whereby a patient can receive state of the art management of a stone by a full-time stone expert. This will require a team of at least 5 endo-stone urologists plus their support team. If it takes around 7000 RVUs to support one urologist, the clinical activity to support such a team can be calculated fairly quickly.

 

7.          Another way to look at departmental size from the educational perspective is to consider the number of surgical cases necessary for a resident or fellow to become proficient at an operative procedure. The numbers vary among the facets of urology, whether pediatric urology, uro-oncology, pelvic-reconstructive urology, andrology or stone management. In the last example, we know that a minimum number of cases for a resident’s experience is 60 ureteroscopy cases, according to our certifying organization. The University of Michigan program of 4 residents a year for a 5-year training program, is organized such that those 60 cases are performed in the first two years of training, therefore we could calculate a need for a minimum of 120 ureteroscopy cases yearly. However, not all these cases are suitable for a novice, some cases will need to be performed mainly by faculty, and in many other instances a resident may not be available. Therefore it is no exaggeration to expect that a robust stone team should be performing at least 200-300 ureteroscopies per year. If it takes, let’s say, 5 clinic visits to generate one ureteroscopy, then a stone team might be expected to see at least 1000 – 1500 patients with stone disease a year. This type of back-of the envelope calculation could be extended to percutaneous nephrostomy cases, ESWL cases, or bladder stone patients.

 

8.          Yet another level of consideration of scale involves how many annual surgical cases are necessary to maintain proficiency. The average urologist in the United States performs less than 5 radical prostatectomies and less than 2 cystectomies annually. Because recent data (and common sense) correlates quality with volume, and it seems reasonable that a urologist who performs 30 cystectomies a year would be your preferred surgeon to someone who performs one a year, or one every other year. Thus a robust institution should deploy surgeons with robust volumes in their areas of expertise. The critical mass ensuing from a team of such surgeons, naturally would favor learning, teaching, and investigation worthy of a strong university. Decisions regarding size of an academic department are therefore most efficiently made within academia at the local level, recognizing that the history, geography, demography, economics, and politics of each institution, best determine its scale and destiny.

 

9.          Lapides & Lyon  Last month we mentioned Jack Lapides, Section Head of Urology here in Ann Arbor from 1968 – 83. Jack’s friend and contemporary Dick Lyon (seen second on your right and self-described as “old man.”) thereupon sent me this picture of Jack from 1975. In their era of practice a urologist was a generic general urologist. Few graduates of residency took fellowships, and most went out into practices that covered all aspects of urology. The world of urology has changed greatly since the days Lapides and Lyon, and considerable impact can be credited to their careers. Subspecialties have blossomed and Dick was one of the very first to identify with pediatric urology. Today it is most unusual in North America or Europe for a significant pediatric urology condition to be managed by anyone but a pediatric urologist, and this effect is diffusing throughout the rest of the world. A similar trend is forming for urologic oncology and neuropelvic reconstructive urology. The same subspecialization of labor is reflected throughout health care, other professions, and the workforce at large. This is an inevitable trend as knowledge accrues and technology expands.

 

10.       While May Day historically celebrates the generic laborer, we recognized this is quaint terminology. Modern cosmopolitan life includes all sorts of workers of all sorts of skill levels. A myriad number of occupations not only contribute to modern civilization, they are the basis of it. Each skill and each job has dignity and should offer further opportunity. The great challenge for government, public policy scholars, and economists is to expand employment and mitigate poverty. All people deserve a chance for meaningful occupation and fair compensation. The most problematic divide in the world today is not between working class and an upper class, or between blue collar and white collar workers. The greatest divide is between the impoverished and the rest of mankind. Lacking viable jobs with sustainable wages that include health care and other benefits of a civilized society, an impoverished sector tends to perpetuate a cycle of poverty with all its attendant maladies. Its members are less likely to contribute to society, more likely to require substantial assistance, and their neighborhoods are more likely to explode, as evidenced this week in Baltimore. As we celebrate all workers in all the many specialized jobs of today, we should recognize the obligation to extend decent employment as widely as possible while maintaining a fair safety net for those left behind. This should be the promise of civilization. 

 

Screen Shot 2015-04-29 at 4.26.20 PM [Medieval Uroscopist]

 

 Garment workers [Garment Factory Workers 1936. Photo Russell Lee, public domain. The Living New Deal Website]

 

Airplane workers  [WWII: FACTORY, 1942. Women installing an aircraft engine at the Douglas Aircraft plant in Long Beach, California. Photograph by Alfred T. Palmer, June 1942. Granger Academic]

 

Post script  (introduction from 2013)

Clues to predict the future have been highly prized throughout the millennia of human history, especially so when the future is related to prognosis of disease and disability. External cues from the heavens, in the weather, via tea leaves, or with playing cards have played major parts in the prediction of health. The logic of using more immediate evidence from physical signs or bodily fluids was evident to early practitioners of medical arts. Humans share the trait with other mammals of daily personal interest in their urine, for example, and its scrutiny during illness was obvious. Hippocratic writings documented uroscopy, as it came to be called, 2500 years ago and over the ensuing centuries the practice elicited imaginative prognostications as healers identified as uroscopists examined the gross characteristics of urine in flasks called matulas and speculated on the course of illness. The visual image of a “piss prophet” gazing at a matula served as the main symbol of physicians in art until only about 200 years ago when the stethoscope replaced the flask as medicine’s badge of office. We begin this electronic journal with a respectful tip of the matula to that original essayist Michel Eyquem de Montaigne who began his eclectic personal observations around 1572 when he was around 39 years of age. It is likely that Montaigne was well acquainted with physicians and matulas, as his father purportedly died of urinary stone disease and Montaigne himself began to suffer from them in 1578. What impulses compel us humans to share our observations and thoughts may someday be revealed through the matula’s diagnostic successors such as the MRI and other marvels of imagination, but there is no arguing that those impulses are strong and prevalent in our species. This blog (finally, I have used the awkward term) is a new forum for the monthly email broadcast I called “What’s New” that I started in 2007 in our Department of Urology at the University of Michigan and with the help of friends have continued regularly since then. These little spaces and sentences will be filled by things that a.) catch my attention and b.) I hope will interest some readers. For the most part this will be an alternative space and presentation of “What’s New.”

 

 

Best wishes, and thanks for spending time on Matula Thoughts.

David A. Bloom

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Matula Thoughts April 3, 2015

Michigan Urology Family

Toolkits & tornados (3916 words)

 

1.   170px-Clovis_Point With April we emerge from wintry mindsets ready for the challenges of spring and summer ahead. Once upon a time these challenges were mainly matters of hunting, gathering, and the immediate issues of survival. Today we take our food, shelter, and security largely for granted; although this holds true for most readers of this electronic column it does not pertain for all of our neighbors. This April finds us with substantial national concerns related to poverty, economy, academic health care, and more fearful existential geopolitical and climactic anxiety for civilization’s survival. These fears are offset to some extent by the excellent human toolkit we have assembled. We have a strong track record as an inventive species building this toolkit, extending back to the Clovis blade seen above (radiocarbon dated 13,200 to 12,900 calendar years ago), a big step in its time for hunting, butchering, murdering, or trimming long beards. At risk of being excessively self-congratulatory as a species, no one can deny that the human ability to formulate ideas and innovate technology is astonishing. The best purpose of such progress, its meaning whether you view our history through a theological lens or a cosmopolitan perspective, is to improve the human condition. Facial appearances, visible testimony to the human condition, have improved along the way since the rough work of early stone blades. On this particular day of the year (3 April) in 1973, Francis W. Dorian, Jr. patented a “dual razor assembly.” Shaving is a pretty widespread human activity, and with nearly 4 billion people on earth in Dorian’s time, you might wonder how it was that he was the one to seize the day with that clever innovation. Nevertheless, he did it and his ingenuity was rewarded. The idea of a patent is to provide an inventor some protection to the sole use of his or her invention before it becomes freely available to the public. Government thus protects innovators for a limited period of time and thereby enhances conditions favorable to further innovation. The first English patent, coincidently, dates back to this same day (3 April) in 1449 in England when John of Utynam was given exclusive privilege by King Henry VI to a specific method of making colored glass. Patent protection was a valuable addition to the human toolkit. [Picture: Clovis fluted blade. 11,000 years old, Copyrighted image – Government of the Commonwealth of Virginia Department of Historic Resources]

 

2.   Pasteur in lab Pasteur used to say, (and Jack Lapides head of Michigan Urology from 1968 – 1983 repeated this phrase often) “chance favors the prepared mind.” Pasteur probably said something like this many times to people in his labs or to his students, but the historically documented quote came from a lecture at the University of Lille on December 7, 1854: “Dans les champs de l’observation le hasard ne favorise que les esprits prepares.” Many of Pasteur’s ideas, on topics as wide ranging as the germ theory of disease and religion were viewed as heretical by some, but his native country respected free speech, liberal inquiry, and peer review thus allowing the best of his ideas to grow and yield even further innovations. Thankfully, no self-righteous hardliners killed him in his lab or on the street and he lived a full life of amazing contribution to humanity. Pasteur criticized the fashion of compartmentalizing types of “science” thus anticipating the beautiful concept of consilience, the unity of knowledge, that E.O. Wilson espoused well over a century later. In 1871 Pasteur wrote (in translation): “There does not exist a category of science to which one can give the name applied science. There are sciences and the applications of science, bound together as the fruit of the tree which bears it.” In this light, the stern separation of basic sciences from clinical sciences in medical school curricula must be viewed skeptically.

Lapides_2

Jack Lapides, seen above, was of a similar mind as Pasteur to challenge conventional wisdom and investigate portions of the world that interested him. Many ideas of Lapides have stood the test of time and his concept of clean intermittent self-catheterization (CIC), that went abruptly against the grain of conventional wisdom in his day, proved to be a revolutionary breakthrough that changed the lives of countless people (you could easily estimate the number in the millions) and opened the door to complex urinary tract reconstruction. Our friend and colleague Bernie Churchill at UCLA has often said that if there were a Nobel Prize in Urology, it would certainly have gone to Lapides for CIC. We have had a paper in progress for nearly a decade on Lapides and hope to complete it soon and then find a place for publication, although that latter issue may prove the greater challenge. [Illustrations: Pasteur in his lab and Lapides in the lecture hall]

 

3.   Knowledge, the substrate of human progress, leads to technology, a signature feature of the human condition. Over time rock-scraping tools became knives that in turn became spears and bow-propelled arrows. Within a countable number of intervening centuries the Swiss Army inspired a universally handy knife and Steve Jobs came along with the iPhone – both of these innovations are in my pockets everyday. Rather than stained glass technology or better razor blades the intellectual products of academic medical centers align to clinical practice, education, and discovery. Our Department of Urology well understands that the generation of knowledge and technology are at the core of our mission. The fusion gene in prostate cancer discovered by Arul Chinnaiyan and his team, and the histotripsy concept and technology (first clinical trials now successfully completed) of Will Roberts and his team are stellar examples of success at Michigan. Physicians are naturally curious about normal biologic function and investigation of normal biologic function and want to investigate pathology of disease. We satisfy that curiosity and investigate infirmities in clinics, at bedsides, in operating rooms, in laboratories, in datasets, in conferences, and in thought experiments. As Pasteur anticipated in his comments on categorization in science we should use the term clinical research more thoughtfully. Clinical has come to imply immediate practical utility for patient care. Research is an approach to discovery using observation, hypotheses, reproducible methods, analysis, and experimentation in many instances. We call this way of thinking science, and validate the discoveries that come from research by peer review and further testing. Some narrowly claim that any worthy research is hypothesis-driven research or randomized clinical trails (RCTs). Such investigations are important to be sure, but not at the expense of raw curiosity, observation, trial and error experimentation, and other methodological study. RCTs work better for drugs in rats than the ever-changing milieu of clinical medicine, and newer approaches such as adaptive design trials are necessarily coming into play. Major breakthroughs ahead of us in knowledge and technology are likely to come from unexpected and unorthodox sources and methods. We should be seeking them and incubating them.

 

4.   What specifically do we want from clinical research? We want better understanding of biology and pathology so as to treat human disease and disability. We want better operative procedures and other therapeutic regimens, including clinical pathways and systems to manage episodes of disease. We want better healthcare delivery platforms and systems. We want better access to care for all people. We want better understanding of the health care workforce and better ways to match it to the needs of people. We want better pedagogical systems for all aspects of the workforce. We want better public health. We want better safety – in healthcare settings, in homes, in the workplace, in transportation, and in food. We want better disaster preparedness and management. All of these things relate to clinical research, including our world of urological clinical research.

 

5.   Twisted lip My comments last month about panhandlers, homelessness, and hunger generated interesting feedback (forgive the double entendre), especially from a few sources of wisdom including Martha Bloom & Julian Wan. The local impact of these problems is visible almost every day on some streets in Ann Arbor, and even more so in larger cities. Mental illness, a huge problem in society, crosses all socioeconomic levels, yet at the lower end of the spectrum mental illness and substance abuse are major factors in the dysfunction of homelessness. Julian reinforced the idea that “not all panhandlers are homeless” pointing out that this is not a new idea. In 1891 Sir Arthur Conan Doyle published the Sherlock Holmes story of The Man with the Twisted Lip built around the idea that a country gentleman, Neville St. Clair, supported his lifestyle by posing as a destitute beggar in London. [Sidney Paget illustration in “The man with the twisted lip.” The Strand. December, 1891. Original caption: “He is a professional beggar”] Also, referring to last month’s Four Freedoms, Julian noted the importance of freedom from social restrictions that has attracted scientists and engineers from other countries to the U.S.A. “not just because of the earning opportunities” but also because they are less constrained by professional and social strictures than in their native countries. This last point is worth considering further. Social and professional strictures are intellectual tools necessary for 7 billion people to get along efficiently and fairly. At issue is the degree of constraint and acceptance of them by those so constricted. For us in western medicine, the Hippocratic Oath is widely accepted, comfortably self-imposed, and meaningful. On the other hand we find regulations that at one extreme may demand certain doctor-patient discussions (e.g. conversations regarding screening tests or surgical procedures) be held and documented in the medical record, while at the other extreme specific discussions such as abortion may be unacceptable or even illegal in some jurisdictions. Few would argue, however, that clinical suspicion of child abuse demands mandatory reporting.

 

6.   Steven Brill’s new book, America’s Bitter Pill, was discussed last month in these columns where I opined that the Affordable Care Act’s (ACA) main effects are here to stay for a while, but may not be sustainable in the long run. The market, the academic community, and the government will inevitably offer up new ideas and experiments. Some may even be good. I read the book word-by-word, but you could save time by going to Brill’s final chapter, Stuck in the Jalopy, his metaphor for America’s healthcare system. He lauds the main intent of the ACA – extending the reach of healthcare to the people in the United States of America. Brill thinks we are destined to spend 16-20%, of the national gross domestic product (GDP) on healthcare. He believes the ACA will further increase the percentage “as employers continue to increase deductibles and blame it on Obamacare.” The government’s share of costs for protecting those without employer-based coverage will also keep rising. He writes: “Expanded Medicaid coverage and expensive premium subsidies will be only partially offset by the taxes, fees, and Medicare savings extracted in those deals with industry.” Yes, millions of Americans now have healthcare coverage with the ACA, but millions of others still do not. Furthermore, many millions, particularly those in the middle class, will continue to struggle to retain healthcare and strain to manage their premiums, co-pays, and other shifted costs. Healthcare, in the ACA paradigm, may be terribly unaffordable for many in the middle class – the part of America that is the engine of its economy. I can’t be very positive regarding Brill’s actual writing. His simplistic solution to our looming national problem consists of 7 “proposed” federal regulations to “free up” the private systems. His questions to President Obama in the appendix struck me as an embarrassment. Nonetheless, Brill provides a thorough narrative of a complex and important topic with careful references and supporting footnotes.

 

7.   Last month in our Departmental What’s New communication, organized by John Wei, we heard about the yearly Urology Joint Advocacy Conference (JAC), a yearly visit to talk to congressmen and staffers. This year Jim Dupree, Gary Faerber, Kate Kraft, Julian Wan, and Start Wolf joined the conference and gave us their observations in What’s New. High on the agenda for nearly 20 of the 30 years of the conference has been the topic of a “fix” to the sustainable growth rate (SGR) issue I mentioned here last month. This is just one of a host of broken parts in Brill’s “Jalopy of Healthcare.” Maybe a bi-partisan fix is finally at hand.  Next year’s JAC will be February 28-March 1, so consider joining in. Talk to our participants from this year. It is inescapable to me that we will be able to manage healthcare in the intermediate or long-term future without a more robust public system, in competition with the private sector just as we have an effective public postal system (yes, Post Office spends more money than it makes, just like the Department of Defense, the Public Health Service, Housing & Urban Development, and the State Department, that all serve the public interest).  The mail analogy is useful. Our Post Office works better because of UPS and Federal Express. And vice versa. The public has options to mail a letter or package practically anywhere in the world. The competition benefits the consumer and keeps each organization relatively lean and honest. If the Post Office were our only option, or alternatively if Federal Express or UPS were the sole supplier of mail services, the public would not be served as well as it is now because of competition. Similarly, national healthcare needs a variety of tools for a variety of conditions – economic conditions, disease conditions, social conditions, and public health. Our VA works pretty well, the Federally Qualified Health Center (FQHC) model works pretty well, and a few public hospitals still function. Public options (a loaded phrase, I know) will ultimately have to expand in number and variety to provide full and fair national coverage as well as to manage costs. In fact, if these are not grown thoughtfully and robustly, the entire private system and our economy remain at risk for a wholesale collapse and unfortunate replacement by a single payer national system. The real competition we need in national health care is not, as many like Brill suggest a matter of Aetna, Vs. United Health, vs. Cleveland Clinic etc. The needed competition is that of those versions of the private sector (“nonprofit” & “for profit”) against other very different models including systems in the public sector.  Government, the private sector, and the world of non-governmental organizations (NGO) in concert and under sensible ground-rules can supply all healthcare needs excellently, equitably, innovatively, economically, and safely. Our problem is how to put this altogether to create a giant Swiss Army Knife for the healthcare of a nation.

 

8.   220px-Wester_&_Co_2 The Swiss Army Knife actually began as a folding pocket knife with a screwdriver for disassembling the Swiss service rifle and a tool to open canned food. Karl Elsener began to make this new type of pocket knife in his cutlery workshop in 1884 in Ibach-Schwyz, but his tinkering lasted 6 years before he came up Modell 1890, shown above. The army liked it. No Swiss company had production capacity at the time and the initial 15,000 knives were delivered by Wester & Co. in Solingen, Germany, in October, 1891, although in time Elsener was able to manufacture the knives in Switzerland. Competition ensued in 1893 when the Swiss cutlery company Paul Boéchat & Cie, (which later became Wenger) also received a contract to produce the knives. Elsener used the cross and shield to identify his product and in 1896 Elsener figured out how to attach tools to both sides of the handle via an innovative spring mechanism. In 1897 an Elsener knife included a second cutting blade and corkscrew that was patented as The Officer’s and Sport Knife, separate from the military contract. After Elsener’s mother Victoria died in 1909 he renamed the company Victoria. In 1921 his company began to use stainless steel (known by the French term acier inoxydable, or inox for short) in the knives and the company was renamed Victorinox. Victorinox and Wenger continued to split the military contract and by agreement the Victorinox product was called the Original Swiss Army Knife and the Wenger was the Genuine Swiss Army Knife. Ten years ago, in April 2005, Victorinox acquired Wenger and again became the sole supplier to the Swiss Army. The two separate knife brands, however, were not merged into a single brand until 2013. The Swiss Armed Forces still issues uniform Soldatenmessers (soldier knives) to all its members. A model incorporating corkscrew and scissors was also produced for officers, but because these additional items were not deemed necessary for survival, an officer was left to purchase the upgrade individually. Recognized by the Guinness Book of Records as the world’s most multifunctional penknife, The Giant, includes every tool ever used in Swiss Army Knives with 87 devices that fulfill 141 different functions. The price is around $1000. Although I am a devotee of Swiss Army Knives (in spite of TSA’s determination to relieve me of them) I don’t have a Giant, and actually prefer the more compact Executive.

1024px-Soldatenmesser_08-2

[Soldatenmesser 08, the knife issued to the Swiss Armed Forces since 2008]

 

9.   Spring with its longer hours of sunlight and daylight savings time brings seasonal downsides that include tornado season in the Midwest. Of course, every season and geographic location has its particular geologic and climactic vulnerabilities, but in Ann Arbor we live at the mercy of the tornado belt, although luckily just at its edges.

1974 super outbreak

[1974 Super Outbreak]

In 1974 North America’s biggest tornado outbreak in recorded history occurred on this day [pictured above]. That Super Outbreak lasted 18 hours with 148 confirmed tornados and a death toll of 315, with nearly 5,500 injured. This was surpassed in 2011 April 25-28 with an outbreak over 3 days and 7 hours, 355 confirmed tornados, and 324 dead. Whether or not anthropogenic climate change is causing more extreme meteorological events will take some time to know, but there is no doubt that extreme weather conditions will continue to wreck havoc.

Severe-Reports

[Kansas City weather report April 27, 2011]

The human tool kit fortunately includes predictive models for weather. Wind, rain, snow, and ice can be treacherous so some warning is helpful. Extreme cold and heat annoy us and push up energy bills, but temperature can be lethal for the more vulnerable people out on the streets. Last month we mentioned that the biennial count of Washtenaw County’s homeless population (performed by outreach workers and community volunteers this past January 28) found 80 unsheltered people sleeping outdoors on the day of the count. While a sad fact, this was less than half the number counted 2 years earlier in 2013 (133), perhaps indicating a positive trend according to the Washtenaw Housing Alliance. The accuracy of climate prediction is steadily improving due to refinement of climate models. [Illustrations: Wikipedia. I did my $100 donation this year and hope a few of you readers also help keep it afloat.]

 

10.  Ideological tornados – tiny and huge. The human toolkit is heavily leveraged to technology, but civilization and our humanity are no less enhanced by the study of what we are, the human condition if you permit the phrase again, through the study of history, literature, and the arts. Some ideas in the human toolkit, while disruptive, have been revolutionary in a positive way leading to a better world as most people would view it. Inevitably, retrograde ideas and schools of thought perpetually challenge our better nature.

•   I’ve recently come to loggerheads with our own journal, the Journal of Urology, established in 1917 and still owned and managed by our profession, the American Urological Association. The journal rejected a paper I wrote and researched with Clair Cox (UMMS 1958, former Chair of Urology University of Tennessee), along with a journalist we encountered in our investigations. The paper was not even sent out for review but was summarily dismissed on the grounds that it was “history.” Our paper explored the reasons for the creation of the first formal national office of the AUA and the interwoven story of the urologic roots of Graceland when it was sold to Elvis. The story is interesting, was largely untold, and required research to discover it. Please don’t view my take on this rejection as a whiny complaint – my emotional balance and career don’t hinge on this publication. I understand that “history papers” in scientific literature may not budge impact factors or subscription rates. Furthermore, I recognize that much previous work in this area has been viewed as “lacking rigor” or has been “celebratory history” (on the assumption that celebration has little merit). On the other hand, few can claim that all “original research” has been worthy. We have seen plagiarism, manipulated data, erroneous conclusions, and undisclosed conflicts of interest, too often. It seems self-evident that all submissions of urological inquiry deserve a chance for peer review by our own journal and by our professional community. Our past is important, our story of urology is important. I suspect this present phase of turning a blind eye to history will fall away to larger and more liberal views within our microcosm of urology (until now our journal over its past 100 years has had a small but rich sprinkling of papers relevant to urology’s history).

•  It’s one thing to disrespect the past, but quite another to purposefully try to obliterate it. Without intending to draw too fine a point of comparison, one finds this trend echoed throughout the world today (and maybe throughout the history of mankind) from small examples such as my complaint to far more sinister levels. The emerging caliphate in the disintegrating nations of Syria and Iraq offers a salient and horrific example, the purposeful destruction of cultural remnants of the past deemed irrelevant or at odds to its fixed apocalyptic vision. Having brought this separate issue up I can’t quite let it go, for it is a geopolitical tornado of the moment. If you want to understand this particular disfigurement of the human condition you might look at Graeme Wood’s article last month in The Atlantic: http://www.theatlantic.com/features/archive/2015/02/what-isis-really-wants/384980/

Wood contends that the so-called Islamic State is no mere collection of psychopaths, it is a religious group with carefully considered beliefs among which are ‘amr – the legitimacy of having territory – and its key agency in “the coming apocalypse”. These beliefs are fixed on an ancient utopian theology intolerant of the progress of ideas that ensued over 1000 years since its 7th century origins. In contrast to Wood, an opposing point of view by Mehdi Hasan “How Islamic is the Islamic State?” in The New Statesman [10 March 2015] argues that it is wrong to view this self-declared state as Islamic. However one views this belligerent group, it does have a central theological claim and an ambitious geopolitical agenda that threatens not only its immediate region, but also the rest of the world. History and current events demonstrate that theologically-based intolerance is hardly a novelty of the Islamic State. Those of us who view the best expression of the human condition in terms of democracy, personal liberty, equality, free speech, education, opportunity, innovation, cosmopolitanism (multicultural society), founded on a basic respect for human rights, and dignity seem to be on the defensive today. Yet as these big ideas have been percolating throughout civilization since that first Clovis Blade, challenges and atavistic regressions have always been at play, testing man’s better nature. These regressions, in a Darwinian way, have ultimately put finer points and better details on Mankind’s best beliefs, and history should reassure us that this trend will continue.

[Ideological tornado. Map courtesy of Institute for Study of War showing territory under caliphate control and areas it has attacked as of March 4, 2015.]

ISIS_Sanctuary_Map_with captions_approved_lo

 

Best wishes, and thanks for spending time on “Matula Thoughts.”

David A. Bloom

 

 

Matula Thoughts February 6, 2015

Matula Thoughts February 6, 2015

Michigan Urology Family

Shapes of content and edges of meaning in winter’s last month.

4020 words

Violet -Shizao

1.    The violet, blooming in very cold weather, is a symbol of February and it would be nice to see a few of those flowers in the ground right now. [Image from Wikipedia, public domain, photographer: Shizhao. Taken 2 December 2007 with Nikon D80] The third month of winter is the most orderly of all months – consisting, usually, of four exact seven-day weeks. This February is especially symmetric, a well-shaped rectangular month with exactly 4 perfectly arranged weeks going from Sundays through Saturdays. Geometry like this is mentally pleasing as we like to find or imagine order and symmetry in the world. These aesthetics make the world seem “right” and perhaps help us to find some sense of meaning. February derived from the Latin word februum for purification. In the old Roman lunar calendar the purification ritual Februa was held this time of year at the full moon. From the business perspective, this month is light with only 20 business days, so the onus is on us to make them as productive as possible. In my pediatric urology sphere, this is challenging due to many unexpected cancellations of clinic visits and scheduled operative procedures because of seasonal illnesses in kids. Nonetheless, efficiency – the very essence of the lean process engagement that we are so committed to in the Medical School and Health System – is the best path to a successful future in academic medicine. Consider what 5% improvement in efficiency means to a three billion dollar business. That’s only a matter of 5% less supplies, 5% less time per episode of care (especially when spent on electronic medical record systems), 5% more new patients seen each week, 5% better utilization of facilities, 5% more productivity of health care providers, researchers, and clerical staff. A Five Percent Solution would produce a healthy new normal for our institution in Ann Arbor a year from now. By the way, next year, 2016, will be a leap year with 29 days of February beginning on a Monday.

 

 

Treaty of Alliance

2.     February 6. Two historic February 6 events have overtones today. In 1778 amidst the Revolutionary War the Treaty of Alliance [pictured] and the Treaty of Amity and Commerce were signed in Paris by the United States and France signaling official recognition of America’s new republic. Ben Franklin led the Continental Commissioners and signed both documents. Without France’s contributions at that time, it is unlikely a United States of America would exist today in its present form. In 1820, 86 African American immigrants sponsored by the American Colonization Society (ACS) left New York to start a settlement in present-day Liberia. That story, however, had begun a few years earlier.

Paul_Cuffee.

Paul Cuffee (1759–1817, illustration from Wikipedia) a successful Quaker ship owner descended from Ashanti and Wampanoag parents, had the idea to settle freed American slaves in Africa and gained support from the British government, free black leaders in the United States, and members of Congress to take American emigrants to the British colony of Sierra Leone. Intending to return with cargo in 1816 he took 38 African Americans to Freetown, Sierra Leone. Later voyages were precluded by his death in 1817, but by reaching a large audience with his pro-colonization arguments and single practical example, Cuffee laid the groundwork for the ACS. During the next three years, the society raised money by selling memberships and pressured Congress and President James Monroe for support. In 1819, the ACS received $100,000 from Congress to purchase freedom for some slaves and to cover the transport costs. On February 6, 1820, the ship Elizabeth, sailed from New York for Liberia with three white ACS agents and 88 African American emigrants. The ACS was unable to get further funds from Congress, but did succeed in appeals to state legislatures. In 1850, Virginia set aside $30,000 annually for five years to aid and support emigration and later the society received additional funds from New Jersey, Pennsylvania, Missouri, and Maryland. 

 

3.     Progress. Liberia, Sierra Leone and Guinea, have been prominent in recent headlines with Ebola largely because they lacked the infrastructure to manage their outbreaks. Liberia is a peculiar construct with origins that were both philanthropic and racist. While the so-called racial divides within mankind have been dissolved by science, insofar as skin color is a matter of dermatologic response to climate (see Nina Jablonski’s work in Science 346:934, 2014), overtones of racism continue to mar human progress. This thought begs the question, what is human progress? On one hand we have a.) the progress of science and technology, although some thinkers argue that such progress only hastens the extinction of our species, taking along countless other species as well. On the other hand, there is b.) the humane progress of equality, education, just government, cosmopolitanism, and fair opportunity. The only sane pathway forward is the latter form of progress merged with science, technology, and economies that respect biodiversity and planetary welfare, but how this can be achieved with failed nations, fragile economies, sectarian warfare, ejaculations of terrorism, and lingering racism is our defining question. Progress is a two-edged sword and you can understand the dark side of it in Roland Wright’s provocative and very readable book, A Short History of Progress. The bottom line in my opinion is that the net result of human progress should be to further a decent, self determined life for everyone, and the same for their children on a sustainable planet.

Ebola%20Map-2

[Ebola map – The Lancet 385:7, 2015]

 

4.     Equality. In an interview towards the end of last year, President Obama said something in his year-end news conference (December 19) that aroused a painful national conversation. In the recent aftermath of the killings of young men by police and point blank assassination of police officers by young men, he commented that in day-to-day interactions America is “less racially divided” than when he took office. This seemed at odds with opinion polls and headline news. We may not feel less divided because issues of racism have been so prominent in the news. Some journalists including Roxane Gay – who reports on race, gender, and identity – agreed with the president noting that these issues are more visible because Americans are being forced to confront a difficult reality, having “been able to look away in the past and we can no longer look away.” [NPR Morning Edition Dec. 31, 2014 interview with David Green] She broadened her comments to include abuses by people in positions of power and a gender rift in which “ … some men feel that women owe them attention, affection, love, sex. And when they are not given what they are owed, there are consequences.” She included examples of allegations related to Elliot Rodger and Bill Crosby. Painful though these discussions may be, in our open society we are able to have these difficult conversations and work through these divides in the hope of creating a better society. This is far from the case in the pseudo state of ISIS and in many places elsewhere in the world. The world is cosmopolitan with 7 billion of us, with no type or group having any more inalienable rights than another. All modern nations should be fair, just, and provide infrastructure for basic human needs and safety, otherwise a claim to nationhood doesn’t pass the muster of reality. Underlying our membership in the human species is the fundamental human moral understanding that everyone deserves a fair shot at a decent self-determined life. This belief requires a commitment to equality, a topic highlighted in Danielle Allen’s work on the Declaration of Independence and her 5 main aspects of equality. These bear repeating: a.) no domination – equality of presence & opportunity; b.) equal access to government and laws; c.) equality in contribution to collective intelligence (everyone’s opinion matters); d.) equality of reciprocity (this one is a key point – the balancing of agency in human relations with the mutual recognition and ability of individuals to recalibrate or redress imbalances in encroachments of freedom); & e.) equality of ownership of public life. Without equality in these 5 forms we have no civilization.

 

5.     Work. Many managers repeat the claim that they want their employees “to work smarter.” This belief carries the conceit that managers, from lofty perches, have access to special insights or technologies that can reform individual productivity at the cottage industry or assembly line level. But really, what worker doesn’t want to work better or more productively, unless circumstances (managers, particularly) provoke a nihilist attitude? An enduring 5% solution is more likely to come from worker-based “smarter work” than a top-down manager-based fiat. It is ironic that throughout all the claims to “working smarter” in healthcare, the talk is related to efficiency and not being better physicians in the senses of diagnostic acumen, clinical skills, communications, kindness, safety, and outcomes. The real magic of our time is found not in the inspiration of a CEO de jour, but rather in the workplace (gemba), where workers using their own expertise of their work and product can unleash their creativity to make things better. This is the idea of lean process engineering, something our organization has focused on sharply. The most salient recent success at the University of Michigan Health System has been the Faculty Group Practice (FGP). This came about when the Hospital in 2007 transferred about 90 Ambulatory Care Units (ACUs) to a regentally-sanctioned clinical faculty group with operational and some fiscal authority. Currently we have about 145 ACUs that are largely managed by the people working within them. We are now transitioning the FGP to a larger organization with greater involvement of clinicians in the strategy, capital decisions, and operational management of the aggregate clinical work of the University of Michigan. The new group will be called the University of Michigan Medical Group (UMMG) – maybe not the catchiest of all names, but it says what it is; the UM Medical Group. New bylaws are being drawn up for this group to define roles and responsibilities that will allow rational and integrated management of our complex health system for the benefit of patients, learners, and knowledge. This is long overdue. Our clinical faculty individually have been swimming upstream trying to provide optimal care for patients, teach the next generation of health care practitioners, and expand the conceptual basis of medicine. The timing for this change is good, with our respected interim EVPMA and alumnus Mike Johns turning over the position to Marschall Runge on March 1. As I write these thoughts I see a new book has just come out by Steven Brill, who authored the Time Magazine single issue called “A Bitter Pill” two years ago. We discussed that work on these pages back then and I’ll come back soon with observations on the book, where he details both the state of American health care and the Affordable Care Act that is changing it.

 

6.     Philanthropy. Pope Francis, perhaps the most philanthropic of leaders on the current world stage, recently spoke of the pathology of power, as we mentioned here last month. He understands better than most of us not only our obligations to others in need, but also how power diminishes empathy. His extraordinary Christmas message to the cardinals and bishops of the Roman Curia, applies perfectly to any large organization whether a department, a business, a university, or a nation. Francis warned against endemic “spiritual diseases of bureaucracy” including the pathology of power, the temptation of narcissism, cowardly gossip, and the building of personal empires. Certainly the Vatican got it right in the mysterious process of leadership succession with him, but this got me thinking why we, as a species, are so inconsistent in this important matter of selecting our next generation of leaders. If Winston Churchill and Mahatma Ghandi were “right” choices as leaders (although they hardly admired each other) Adolph Hitler and Pol Pot were not. Hitler and Pot hijacked their nations and led them into war, genocide, and countless other crimes against humanity. How can a single leader control millions of people, especially if that leader serves interests counter to most of those people? The best defense against this Achilles’ heel of our species seems to be free speech, shared belief in equitable human rights (cosmopolitanism), and representative government. If crimes against humanity are the dark side of human nature, good deeds for humanity are the bright side – and this is the nature of philanthropy. The human species is a wonderfully diverse lot and it is by means of the very diversity, in the Darwinian sense, that the best hope for the future lies. This is the essence of cosmopolitanism. The great beliefs of the Reformation and Enlightenment have led to the work in progress of representative government as you see in the United States, Canada, Great Britain, France, Germany and many other nations. One perplexing irony is within these free nations, extremist views of barbaric individuals are allowed free range. These views can act like mental viruses in susceptible individuals who then translate extremist sectarian or political thought into uncivilized, undemocratic, un-cosmopolitan, and villainous action. Powerful thoughts can diminish empathy regarding alternate ideas and the power of a weapon magnifies the disease.

 

7.     Meaning. Our brains are hardwired to relate to some types of information better than others. Information whether sensory, narrative, or numeric allows us to resolve uncertainty and understand the world. Spatial information and stories, for example, are more meaningful to most people than numeric or abstract information. Spatial information may be sensory – we have proprioceptive skills and we have spatial neurons that mark our place in environments – and spatial information may also be conveyed by analogies, something the human brain does so well. Education, the vanishing species of liberal education most especially, sharpens the critical thinking of individuals, exposes them to a wide range of ideas, and prepares them for life in a cosmopolitan world. Being productive and creative in that world people can meaningfully better that world of today and the world of tomorrow. A colleague and friend here at the University of Michigan, James Boyd White, wrote a book I’ve enjoyed called The Edge of Meaning. The spatial analogy of edge is a brilliant metaphor implying some sort of intellectual border to that space we crave to access, as befits our biologic name, Homo sapiens. [White. The Edge of Meaning. University of Chicago Press, 2001]  The Preface begins with this paragraph. “Though we have no very good way of talking about it, one of the deepest needs of human beings – perhaps of all our needs the one that is most distinctly human – is for what we in English call meaning in our experience. It is meaning that we seek to create through our cultures, those complex symbolic and expressive practices ranging from music to politics, football to religion, that occupy us so much of the time; and meaning, perhaps in a somewhat different sense, that each individual seeks as he or she works through the choices and possibilities of existence, trying to make them add up to something whole and coherent.” Powerful thoughts.

 

8.     Content & shapes. In its most basic sense content to a child is stuff in a box. As we grow up we learn that a table of contents is a organized listing of things, most usually in a book. The digital world has broadened our sense of content to include (according to our friend Wikipedia) “information and experiences that provide value for an end-user or audience.” While content is more than noise in the universe, one might argue that some content (experiences and information) might be meaningful to one person, but mere noise to someone else. In some instances what appears to be noise at first, may be perceived as meaningful content after study and analysis. It is increasingly difficult in this age of information, accelerated by the growing world wide web, is to discern content that is meaningful to us individually. This is another level of the signal vs. noise dilemma: some content rises above routine interest or utility in that it provides meaning about our lives with insights into our values, our human nature, and our personal character. We assume such self-reflection is unique to the human condition, or perhaps the “higher ape condition” – who really knows how unique we are? Nevertheless, our brains are fine tuned to search for meaning, as if we need “p-values” for our existence. Another geometric metaphor is found in the title of Ben Shahn’s book, The Shape of Content. Of the varieties of information our brains receive – sensory, narrative, and numeric – the sensory and narrative forms are the one most of us relate to best. Shapes, one might argue, offer a sensory form of information that is both visual and tactile in our imaginations in that you can visually “feel” a circle, triangle, and rectangle. I found Shahn’s old paperback in a funky bookstore in Atlanta. The visual work of the author, a great American artist and illustrator, was familiar to me and my daughter (now an assistant professor of English at Georgia State) but not his written work so I picked up the somewhat battered copy for her. It was curiously priced way beyond its initial cost in 1957. Subsequently I’ve found much cheaper newer editions available though Amazon, but I would never have known of it had I not seen it on the shelf in the eclectic shop. (It will indeed be a minor crime against humanity if the next generation of Homo sapiens has only Amazon for its bookstore.) I have quoted from Shahn before and I keep finding new treasures in his book including this: “Content, I have said, may be anything. Whatever crosses the human mind may be fit content for art – in the right hands. It is out of the variety of experience that we have derived varieties of form; and it is out of the challenge of a great idea that we have gained the great in form – the immense harmonies in music, the meaningful related actions of the drama, a wealth of form and style and shape in painting and poetry.” [Shahn. The Shape of Content. Harvard University Press, 1957. P. 72]

 

 

9.     Feb HeuresBack to February. While you will find no urological themes in the beautiful shapes and content of the Très Riches Heures du Duc de Berry – its February illumination is well worth a look on these cold days in the northern hemisphere. This work, painted around 1412-1416 for John, Duke of Berry (a Donald Trump of a sort for his day) was a book of hours, a collection of prayers to be said at canonical hours. An illuminated page introduced each month and the February calendar miniature, believed painted by Paul Limbourg, shows a sheep pen, bee hives, and a dovecote next to a small house where three young people and a cat relax in front of a fire. A person on the right seems to be walking to the house while blowing on his or her hands to warm them (you may relate to the frigid scene this winter). In the background a man chops wood while another leads a wood-bearing donkey to a village. Above the painting is an astronomical chart with a solar chariot and signs and degrees of the zodiac. [Illustration from Condé Museum – located inside the Chateau de Chantilly in Chantilly, Oise, 40 km north of Paris] As you look at this quaint genre scene, you may realize that not much has changed in 700 years. People still get on with life, make their livings, seek comfort, enjoy diversion from their work, and look for patterns, harmony, and meaning as reflected in the astronomical chart. Lives come and go, but life musters forward.

It is rumored that the first six weeks of each new year comprise the most treacherous span for human mortality, absent the influences of war and natural disaster. I don’t know if this is statistically true, a northern hemisphere phenomenon, or what, but just in the past few weeks 3 dear friends of nearly exactly my age died suddenly and wrenchingly. They each left a lot – great families and friendships to be sure, but more than that. Each had a distinct form of optimism and pluck, perhaps enhanced by previous close encounters of the terminal kind, but probably equally due to their own native kindness and aequanimitas. This last word was a favorite of Sir William Osler who used it to mean imperturbability, although more broadly the term means goodwill, kindness, equanimity, and patience. It is the very essence of humanity and fits so well with Thomas Shumaker, Thomas Adrian Wheat, and Gordon McLorie. Mentioned and shown in order of their loss, each in his own way enriched the content of lives around them, mine included. Humans may be the only species impertinent enough to ask the question what is the meaning of life. Descartes thought it sufficient to understand that “we think, therefore we exist.” James Boyd White suggests that we are capable of going further, to the edge of understanding meaning with the tools of language and imagination. Tom S. (a lawyer and son of one of the founders of pediatric urology), Adrian (Army surgeon and professional grade historian of Confederacy Medicine), and Gordon (fellow pediatric urologist, world traveler, and co-trainee from our UCLA days in the early 1970’s) lived lives of rich meaning. Their families, personal friendships, and professional contributions are certainly exemplary in terms of meaning. Yet beyond that, their aequanimitas, each in its own way, modeled the essence of humanity, how we as individuals stay glued-together enough to muster on constructively to build better tomorrows for our collective children. That process of mustering on with aequanimitas to create a better tomorrow for our descendants is what makes up the meaning and fulfillment of life. These men did it well.  All species strive to muster on, but aequanimitas is our human touch.

Shumaker T  Adrian  Gordon

 

 

10.    Mission, & essential deliverable (our declaration). How can an organization best carry out its mission and essential deliverables? It helps if the organization’s work is meaningful to society. Even more so, if the work is meaningful to tomorrow’s society, namely that of our children in the broadest sense. If members of an organization are aligned believers in their mission and essential deliverables, the team has a chance at greatness. In doing its work exceptionally, the team can inspire itself, will inspire its learners, and will inspire other teams. Teamwork is the fundamental necessity of civilization and a highly performing team is the most effective and civilized form of organizational function. This brings to mind a sports metaphor and so I return to the 1936 Olympic 8-man rowing crew that is as good an example as you can find. I was on the crew of the rowing team of my small high school in Buffalo New York and we practiced at the West Side Rowing Club, an organization that clearly had seen far better teams performing on the water, so you may be relieved to learn that the sports metaphor is not mine. I can only imagine what we looked like to seasoned observers. So let me return to Dan Brown’s account of the 1936 championship crew from the University of Washington. It’s a compelling and accurate story, mentioned previously in Matula Thoughts, of the formation and performances of a highly effective team, perhaps as fine of an athletic team as has existed. We respond to the beauty of great athleticism and teamwork in all sports, but crew is in its own world, indeed even its name refers to the team and not the actual activity. Unlike baseball, for example, where the team features highly individual performances, yet may execute lovely moments of teamwork, 8-man rowing requires 8 exquisitely coordinated and relentless athletic efforts coordinated minutely and steered by a coxswain making a perfect line through water and space. That teamwork and geometric execution are what we try to emulate with our UM Urology Department, our Medical School, and now with the UM Medical Group.

Crew 1936

[University of Washington underdogs, given the least favorable position at top lane, finished ahead of Italy and Germany in foreground]

 

Best wishes, and thanks for spending time on Matula Thoughts this month.

David A. Bloom

Ann Arbor, Michigan

 

 

Matula Thoughts January 2, 2015

Matula Thoughts January 2, 2015

Michigan Urology Family

Watersheds, leadership, & 2015 again

3676 words

 120px-Glycine-zwitterion-2D-skeletal

 

1.     Happy New Year. Its hard to believe 2015 is already here, but this fact reminds us once again that the forward march of time is relentless and time runs backward only in our imagination. History, nevertheless, still defines us with each new minute, new day, and new year serving as a watershed framing the past and future. This new year of 2015 is a significant watershed for everyone who will reach a milestone age in it, whether 40, 50, 60, 70, or even more years having enjoyed the contingencies of genetics, circumstance, modern health care, physical safety, and luck. As I begin the year at a significant personal watershed Gary Faerber is already in place as Acting Chair, following the previous turns of John Wei and Stu Wolf, who then returned to their roles as Associate Chairs with quantum leaps in knowledge, talent and leadership for the department. When Dean Jim Woolliscroft and I set up this experiment in leadership succession a few years back, I had no doubt it would be successful, but hardly imagined the great degree of success. Leadership is something everyone provides at one level or another in our organization, as well as within their families and communities. Leadership is a focus for us in our department, and certainly no less in the rest of the university from our valiant football team among the other athletic programs, throughout the 19 schools and colleges, in the Musical Society and a myriad other parts of the UM as it approaches its bicentennial. No one, even among the overpraised CEOs who write best-selling memoirs, is a perfect leader at every challenge in their life and career. Published perspectives, naturally tend to be self-congratulatory vignettes of successes, usually with sparse mention of the shoulders of giants on whom such leaders have stood. Plenty of more general leadership books are available, a few of them worthwhile, and you can always discover more about the topic if you are intent on developing your skills. The best way to learn, I believe, is to take the initiative yourself and try to lead wisely, be self-critical and learn from your mistakes, as well as to learn from the examples (successes and failures) of other leaders. We have some fine role models among us in the Medical School and Health System as well as within our professional peers elsewhere. Flawed examples of leadership (sometimes found in our own mistakes) offer equally valuable lessons. On the national and international political scenes noteworthy leadership seems  sparser. Looking back to the 20th century only rare great examples come to mind.

 

 

2.     WSC 1874-1965. It was 50 years ago that Winston Churchill died having reached 99 years of age in spite of innumerable bullets, cigars, prodigious quantities of food and drink, to say nothing of his determined political adversaries. His death in 1965 was a significant watershed – few people have so completely and uniquely altered the course of human events as did Churchill,  on a number of fronts including 2 World Wars. Admittedly a Churchillphile, I nonetheless recognize his many imperfections, yet he was the perfect man to rescue the course of history from catastrophe. You can expect a number of new books published about him this year and one of the first of these is by Boris Johnson, the mayor of London. Many biographies and studies of Churchill have been written (and at least a dozen fill my shelves), but Johnson’s The Churchill Factor occupies a unique niche offering a timely analysis of Churchill’s  impact on civilization. The world would be very different today had it not been for Winston Churchill. Someone other than Gutenberg would have figured out the printing press, and the same goes for the contributions of Columbus, Watt, Darwin, Lister (eventually!), Ford, Gates, and most other innovators. Only a rare few individuals have turned the tide of world events so positively and against such great odds. Without Churchill the second half of the 20th century and probably these past 15 years into the 21st would have been very dark times. Amazingly he was around 70 years of age when his greatest tests presented themselves. It is inconceivable that World War II would have turned out as it did without Churchill.      

 winston_churchill 

[Churchill  at 10 Downing St. 1940, by Cecil Beaton]

 

 

3.     Impact. None of us is likely to have impact of Churchillian proportions, but that’s not to say that as individuals we are not serious about making a difference. At any watershed moment each of us is likely to question “the meaning of life.” I recently listened to the audiobook autobiography of the controversial evolutionary biologist Richard Dawkins wherein he said something to the effect that “Intelligent life only comes of age when it works out the reasons for its own existence.”  [Had I read the actual book I could be more precise and reference a specific page; whether you agree or disagree with his theological viewpoint, his evolutionary biology contributions have been significant.] All life forms struggle for their survival searching for a difference, whether a favorable environmental differential, a nutritional differential, or a reproductive differential. We humans share this biologic imperative of curiosity to discover favorable niches, but our drive goes further into the superorganism of our civilizations in that we want to “make a difference” in the social sense. For many people this drive is satisfied by a sense of being taken seriously, wanting our opinions to matter to others. For other people this drive is expressed in intense ambition to invent, create, build, or help others. The individual need to make a difference is part of the rich fabric of sociobiology, allowing brilliant flashes of greatness such as Churchill in his day and Pope Francis now in our time. The Pope’s extraordinary Christmas message last week to the cardinals and bishops who make up the Roman Curia, could apply equally well to any large organization. Francis warned against endemic “spiritual diseases” of bureaucracy including the pathology of power, the temptation of narcissism, cowardly gossip, and the building of personal empires. His courageous and unprecedented speech hinted at the darker side of sociobiology, namely the innate tendency of any social group (political, religious, ethnic, or national) to be manipulated by a single autocratic leader or inner circle of leaders toward ends inimical to the larger shared values of not just the particular social group but to humanity at large. Pope Francis is one of the rare leaders with the credibility and force of character to bridge disparate factionalisms within his organization or in the larger geopolitical world by appealing to a human commonality. With all the problems in the world, you might think we are overdue for a few more extraordinary leaders like Churchill and Francis.

pope-francis-ap2_custom-35b090fdb44d1cd3207660a63e5d93856a112c0a-s600-c85

[Front left to right: Israel’s President Shimon Peres, Eucumenical Patriarch Bartholomew I, Pope Francis, Palestinian President Mahmoud Abbas – June, 2014 during peace prayers at Vatican gardens]  

 

 

4.     Sociobiology and mission. The idea of sociobiology, initially postulated and named by E. O. Wilson, recognized that a very few species – humans among them – have achieved a superorganism structure wherein individuals spend their lives to support the objectives of larger social structures of teams and societies. He called these eusocial species. Humanity alone, however, has been able to articulate social objectives, create principles and working rules for their deployment, and produce functional models of government. Our work in the Department of Urology of the Medical School within the University of Michigan, while minute in the grand scheme of things, fits in perfectly within the sociobiology framework. Like any individual, any team, or any large eusocial unit we are subject to the same evolutionary pressures of maintaining relevancy and preparing for the changing environments of tomorrow. We spend significant time in our Department of Urology considering and reconsidering our mission. While I dont believe a leader should tell any organization its mission, I do believe that a leader should help the organization articulate its mission as well as keeping it lively in the work, plans, and lives of its stakeholders. Our mission of Michigan Urology is centered on health care: teaching it, doing it, and making it better. It boils down to this essential deliverable: KIND AND EXCELLENT PATIENT-CENTERED CARE THOROUGHLY INTEGRATED WITH INNOVATION AND EDUCATION AT ALL LEVELS. We mean it and we believe in it. Our mission here goes deeper than those specific words. We are a great public university with a medical school influential in the story of modern medicine. Our urology unit has provided many of the best ideas, techniques, and leaders of our field for the past century. I can point to strong evidence of our successes in the weekly Whats New electronic communication that John Wei coordinates for our department that you can find on our website. When you really consider our mission, you might recognize that our mission is to provide for tomorrow the tomorrow of our patients, our students, our residents, our department, our faculty and staff, our community, our field, our children, and our species. We thus fit very neatly in the milieu of a university – universities exist to make tomorrow better. No organization in human civilization aside from universities has carried out this specific responsibility of preparing for tomorrow, year after year, decade after decade, and century after century.  In the daily struggles of finances, politics, governance, and crises most universities plod ahead it is their nature to be conservative – doing their work well enough although below their potential to build that better tomorrow.

 

 

5.     The future. Imagining the future is also a task of art and fiction. The Time Machine of H.G. Wells, the stories of Jules Verne, Orson Welles’s War of the Worlds, and for our present generation the Back to the Future film trilogy are stories that resonated with me on the back end of my present watershed. The first of the trilogy was set in 1985 and it imagined a future set in 2015. In that future the gimmick that made time travel possible was a plutonium-fueled flux capacitor (which needed a jolt of lightning to start it when Marty went “back to the past” in 1955 and he couldn’t find plutonium). Going forward to the future, however, the flux capacitor’s energy required only household waste in a commonplace “Mr. Fusion Home Energy Reactor” in 2015.  We aren’t at that point yet in terms of energy production, but since we can imagine a Mr. Fusion Reactor, it seems likely someone or some team will eventually solve this existential problem. Back to the Future excited the public imagination to the extent that it was the largest grossing film of 1985. I loved it, my kids loved it, and my grandkids love it. What are the counterparts of the Mr. Fusion Reactor for urology, or for health care in general? Perhaps the best insights for this will come from people writing imaginative short stories.

 

 

6.      Predictions. Yogi Berra allegedly said: “Its tough to make predictions, especially about tomorrow.” Each New Year is full of promise and challenges, some expected and others unexpected. If we could spot the specific key threats and opportunities right now at the start of the year and plan around them we could take those plans to the bank, as they say. While we don’t have the gift of foresight or the mythical “Gray’s Sports Almanac” that was central to Back to the Future Part II, we still could make some good guesses. If, for example, we knew a large asteroid was headed our way (another theme explored in the cinema) we might take steps to ameliorate it. Or if we knew an Ebola-like disease were likely to become epidemic we might create a vaccine and public health measures to manage it. (Remarkably we’ve known about Ebola since 1976, but somehow were unprepared for it last year.) It’s not always as tough as Yogi thought. Even without Grays Almanac we can make serious bets and useful decisions. We actually have figured out some forms of time travel of which astronomical sciences and space probes are outstanding examples. You might consider literary science fiction a form of hypothetical time travel to the future.

 Sports Almanac

[The pivotal sports almanac, stolen by Biff in 2015 and taken back to November 12, 1955 when he made some lucrative bets.]

 

7.     Challenges 2015. What will be the immediate challenges for Michigan’s Department of Urology in 2015? At the top of my list is the matter of struggling to stay afloat economically in a punishing economic milieu. We have around 30 clinical faculty doing the actual clinical work that 16-17 full-time clinicians could perform, and doing that work at the top of the game. Why is this? The answer is that, as faculty members in a university, our non clinical moments are spent in educating the next generation, expanding the conceptual basis of urology through investigation, supplying a large amount of administrative expertise and effort to run our heath system, and leading regional, national, and international organizations relevant to urology. The fiscal problem is that even at best these other tasks that are so essential to our missions have zero to only fractional revenue streams to support them. Clinical dollars have made the academic missions possible, but those dollars are shrinking under ruthless pressure. Our aggregate faculty carries a phenomenal portfolio. As the person tasked with paying the bills I am challenged in recruitment and retention by more generous compensation schemes at most of my peer institutions. Like most of my fellow chairs, I face inimical wealth redistribution from the heath system to our greater university, the inefficiencies of our own hospital (as a patient here myself while I had great care from individuals and teams, I also experienced a number of disconnects that Ritz-Carlton might consider rookie errors in the hospitality business), and severe facility constraints  based on 20 years of inadequate strategic planning and execution. Maybe with a new university president and EVPMA in addition to a restructuring of our health system governance and management we might finally get things right. Do the new leaders recognize that the key to success for a great academic health care enterprise is (first and foremost) great clinical care? On the forward side of this immediate watershed the winners in health care (the best of class survivors in the Darwinian sense) will be the few places that offer unsurpassed state-of-the art clinical care with the best outcomes, safety, patient experience, employee experiences, lean processes, educational outcomes, research productivity, and successful fiscal spreadsheets. If the new leaders are not evangelically wed to this belief and fail to elicit the wisdom of crowds and the opportunities of lean processes, success will slip further and further away. The single large success I believe we can claim over the past decade here at Michigan has been the Faculty Group Practice, led by David Spahlinger. We are now poised to re-structure and expand it into the University of Michigan Medical Group. Will this new format embolden us to find opportunities to reinvent and optimize healthcare in 2015 or will we continue to struggle to stay in the game? I for one favor the former scenario – after all we call ourselves leaders and best? I believe 2015 is now or never for us.

 

8.     A watershed molecule. Eleven years ago on this day (the leap year 2004) the spacecraft, Stardust a 300 kg robotic space probe launched by NASA in 1999, successfully flew past Comet Wild 2, collecting cosmic dust samples from the coma of the comet. Wild-2 is as old as the Earth and was discovered in 1978 by Swiss astronomer Paul Wild. For most of its time the comet orbited the Sun in the far reaches of the Solar System until 1974 when its orbit was changed by the gravitational pull of Jupiter bringing it just inside the orbit of Mars on its closest approach to the Sun. Its orbital period has thus gone from from 43 years to six years. Wild-2 has a 5 km diameter that wouldn’t do us much good if it came much closer to Earth’s celestial path. Stardust fulfilled its mission and returned to Earth in January 15, 2006 with its samples. Initial findings of the analysis were published in papers in Science in December, 2006. Analysis of the comet’s dust by a mass spectrometer on board revealed, among other things, glycine – an amino acid of great importance. Among the 23 proteinogenic amino acids, glycine is not only the smallest, but an organic chemist might consider that it is the smallest one structurally possible (it has a molecular weight of only 75 and its codons are GGT, GGC, GGA, and GGG). This is also the only non-chiral amino acid. Most proteins have only small amounts of glycine, although collagen consists of about 35% glycine.

120px-Glycine-zwitterion-2D-skeletal

A science fiction writer might conjecture that this was a watershed molecule between simple cosmic elemental combinations and the complex organic structures that comprise the building blocks of life. What glycine was doing in interstellar space boggles the imagination, but it fuels the belief of many that building blocks of life came to Earth. Water was also discovered among the comet’s bits of dust, although that was expected. To analyze the interstellar dust further, one million photographs will ultimately image the entirety of the sampled grains. The images will be distributed to home computer users so they can aid in the study of the data using a program titled, Stardust@home.

[Wikepedia: Top left – fuzzy blur of Wild-2 in space, top right – 

the comet close up , Bottom- Stardust] 

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9.     What’s New – reprise. Early in Y2K when I was working in Allen Lichter’s Dean’s Office, we began a monthly email to all the medical school faculty that we called What’s New. The belief was that some occasional, constrained, predictable, and enumerated communication to the entire faculty might be useful, interesting to some, and preferable to a constant stream of regurgitated and often random messages of deemed importance. When I became chair of urology we produced a weekly What’s New for faculty and residents, with only very rare other communications. This went out every Friday. In time I began to distribute the first of these editions on the first Friday of each month to our entire staff, Nesbit alumni, and friends of the department. As the email chain got a little tricky to manage I learned to set the first Friday What’s New up as a blog that we call Matula Thoughts. It has been a learning process and it still is a work in process. John Wei, as Associate Chair for Communications, manages the 3-4 other What’s New columns every month and usually has someone or some unit within our department “guest edit” each of these. He has innovatively added a little query to each issue to test the waters of opinions within our department.  If you ever want to roll back the pages of time for Michigan Urology since 2007, you can find old editions kindly archived by Rick Saur.

 

 

10.    Screen shot 2014-12-28 at 10.10.09 AMMatula Thoughts – going forward. You may fairly view What’s New and Matula Thoughts as displays of vanity. On the other hand, don’t we all want to believe that our thoughts matter to others, and in setting them down and presenting them in the public marketplace of opinions we shape them, we refine them, and we test their value (and by their proxy, our own individual value). For me to some extent, these columns have become forums to comment on phenomena, questions, papers, books, or events that I think are worth your consideration. Equal rights to thought-sharing is a fundamental basis of any democratic society, or indeed the basis of any highly-performing team. We set up these little forums of What’s New and Matula Thoughts not just as our departmental soap-boxes, but as a venue for others such as you in which to participate. What’s New is sent out by email to around 550 people, whereas Matula Thoughts, the blog version that we have been struggling to master, is picked up by a much smaller but more diverse band of readers. Even though the blog version has only a small readership at this point in time, we can track it and have found a surprisingly wide international reach as the screen shot above shows. [I took this December 28 from the WordPress statistics page for Matula Thoughts] The Canadian readership may be huge in terms of geography, but I doubt we actually have many Inuit readers. We invite (indeed, we often cajole or nudge) others onto these electronic soap boxes each week.  It is has been said that some professions attract people with extreme forms of narcissism, politics and professional sports being notable examples. Surgeons probably belong closer to one end of the spectrum than the middle. Yet we humans are all necessarily narcissistic to some extent, and the need for the interest of others, if not their admiration, is perhaps a surrogate for our very basic desire for personal relevance and meaning. Of course extreme narcissism, in its sense as a personality disorder (an interesting term in itself, for what is it, after all, that constitutes an ordered personality?) is the overwhelming need for admiration paired with a severe lack of empathy toward others – the antithesis of a good clinician. As physicians and surgeons, as faculty and staff, as nurses or PAs or MAs, as colleagues and friends we all reverberate to the belief that our thoughts matter and therefore, of necessity, the thoughts of others must be heard and considered with the same relish that we offer our own. So with that last thought at this watershed moment, Happy New Year, and good luck to us all now that we are back to the future in 2015.

 

 

Best wishes, and thanks for spending time on Matula Thoughts.

David A. Bloom

Department of Urology

University of Michigan Medical School.

 

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