Matula Thoughts February 6, 2015

Michigan Urology Family

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

4020 words

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.

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 (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 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.     Back 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.

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.

[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

Michigan Urology Family

Noise, imagination, reality, Nobel thoughts, & wisdom

12 items plus illustrations, 15 minute read (3386 words)

1.     November 7 is here with a bang. Many of us wonder how the 11^th month arrived so quickly, but here it is and Thanksgiving is just around the corner. Our PGY1s must be especially thankful to be reminded that their internship is nearly halfway complete since their steep learning curves probably eclipsed all sense of time and space, but even those of us further along on the learning curve (that asymptotic curve of mastery we mentioned last month) are surprised to find calendar year 2014 drawing to a close so swiftly. The daily noise of work and life overwhelms the limited bandwidth of most humans and dampens the sense of passing time. The world is noisy and in a historical sense this particular day was as noisy and random as most. For example in 1492 a meteorite with the oldest known date of impact struck the Earth thunderously around noon in a wheat field outside the village of Ensisheim, Alsace, France. This inexplicable phenomenon certainly altered the usual sense of order for those who saw or heard it – although the conventional wisdom of wise people then and now is the expectation that “stuff happens” in life. Still, we all like explanations; astronomy and other sciences have since cleared up the mystery of Ensisheim and the offending 250-pound chondrite space rock now sits on display in the town hall. In 1786, more pleasantly on this day, the Stoughton Musical Society, was founded, becoming the first musical organization in the U.S.A.. In a hail of gunfire on this day in 1908 Butch Cassidy and the Sundance Kid were killed in San Vicente, Bolivia. In 1940 on November 7 in the state of Washington, the original Tacoma Narrows Bridge,  noisily collapsed in a windstorm. This day in 1944 was politically significant because Franklin D. Roosevelt was elected to his fourth term as President of the United States of America. Coincidentally, his wife Eleanor Roosevelt died exactly 18 years later on November 7, 1962.

2.     Roosevelt quotes. Earlier this autumn you may have seen the amazing Ken Burns Roosevelt documentary aired on PBS. Two enduring quotes came from these remarkably similar and dissimilar distant cousins. Teddy said “speak softly, and carry a big stick” at the Minnesota State Fair on September 2, 1901 four days before the assassination of President William McKinley that thereby thrust Theodore Roosevelt into the presidency. Roosevelt had mentioned the phrase in an earlier letter (January 26, 1900), attributing it to a West African proverb, but his final version became a fitting encapsulation of TR himself as seen above in the 1904 political cartoon by William Allen Rogers. The most memorable quote of Franklin Delano Roosevelt came on March 4, 1933 in his first inaugural speech: “So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself – nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance. In every dark hour of our national life a leadership of frankness and of vigor has met with that understanding and support of the people themselves which is essential to victory. And I am convinced that you will again give that support to leadership in these critical days.” In those very dark days of the Great Depression and American isolationism FDR’s words gave strength to a fearful nation.

Picture [FDR, his dog Fala and Ruthie Bie at Hill Top Cottage in Hyde Park, the better of two known pictures of the president in a wheel chair. Franklin Delano Roosevelt Library, Library ID 73113:61]

3.     Nesbit reunion notes. Last month in October we hosted the Nesbit Society Meeting here in Ann Arbor. On Thursday we heard excellent talks by Anne Pelletier-Cameron on synthetic midurethral sling failure, John Stoffel on detrusor sphincter dyssynergia in patients with neuropathic bladders, and Bahaa Malaeb on complex revisions in artificial sphincters. These were followed by first-rate case presentations to our Visiting Professor Victor Nitti of NYU by Miriam Hadj-Moussa, Michael Kozminski, Amy Li, and Yahir Santiago-Lastra. Victor, a thought leader in neuropelvic reconstructive urology, spoke about surgical correction of stress incontinence from the perspective of a seasoned surgeon in an evidence-based world. The residents then took our guest to dinner and no doubt peppered him with questions. On Friday John Bacon spoke movingly about Bo Schembechler and the “lasting lessons” of his legendary career that affected the character and lives of the many people he impacted. We then heard from our own faculty: John Hollingsworth on metabolic stones, Ted Skoleras on prostate cancer survivorship, and Todd Morgan on liquid biopsies for genomic profiling of advanced prostate cancer. Dr. Nitti returned to the podium with a clear and instructive keynote lecture on bladder emptying problems. Surendra Kumar discussed radiation therapies for high risk prostate cancer. Julian Wan, our Nesbit Society President, gave an entertaining and wide-ranging talk “Why we won’t cure cancer in your lifetime.” Quentin Clemens presented an update on his extensive and well-funded pelvic pain research network, John Park spoke about his extraordinary Disorders of Sex Development Program and Clinic here at Michigan, Jim Dupree spoke about hypogonadism and the reproductive-aged male, and I gave a brief update on the state of the department. At the business meeting Ann Oldendorf presided over the business meeting and concluded her splendid service to the Nesbit Society.

[John Stoffel, Yahir Santiago-Lastra, Victor Nitti, Linda Ng]

[Nesbit Society at Michigan League]

[Day 2 of the Nesbit – in the Michigan League]

[Halftime show at The Big House from Sincock Suite]

4.     Award & victory. At the Nesbit Society reunion dinner at Barton Hills Brent Hollenbeck was surprised when his name was called out to receive the John Konnak Award. [Picture at the dinner: DABloom, Betty Konnak, Brent Hollenbeck, Julian Wan, Ann Oldendorf] We had good representation from past classes of Michigan and Nesbit alumni at the dinner. Saturday featured the Nesbit tailgate and the Michigan Penn State football game. The halftime show in the dark was an amazing experience for the 113,085 in attendance. A 18-13 victory over Penn State lifted spirits, as it has been a rough year for Michigan football, but win or lose Brady Hoke is a wonderful man and a fine coach who, if given the chance, will bring the scoreboards back in our favor and meanwhile serve as a first rate mentor and leader for student athletes.

5.     Fiction. The human element has a distinguishing feature of a boundless territory of imagination that is essential to our lives in the “real world.” In the pages of What’s New/Matula Thoughts this past September we considered a short story, The Death of Ivan Ilych, as a case report of untreated renal cell carcinoma. Coincidentally a few weeks later I read a book review of Atul Gawande’s newest book Being Mortal, and the reviewer Janet Maslin [NYT October 17, 2014] and I’ll quote her since I’ve not yet read the book. “Atul Gawande’s Being Mortal: Medicine and What Matters in the End introduces its author as a myopically confident medical student whose seminar in doctor-patient interaction spent an hour on Tolstoy’s novella The Death of Ivan Ilych. As a young man he was not ready to understand the title character’s loneliness, suffering, and desire to be pitied. He saw medical compassion as a given and Ivan Ilych’s condition as something modern medicine could probably cure. He and his fellow students cared about acquiring knowledge and competence. They did not see mortality as part of the medical equation.” Well said. As a medical student and resident x2 I don’t think I really “got it” either. But the story of Ivan Ilych, and likely many other stories lurking in subconscious memory banks helped nurture the first glimmers of eventual wisdom. Truth and fiction are inextricably enmeshed in each other, and the value of the latter in understanding the former is continuously astonishing. Scientists and physicians in particular are well-served by a robust amount of “fiction” in their reading repertoire. The truths discovered in the stories we read – truths often strongly linked to health and disease – bring us closer to wisdom, the elusive Higgs boson of our intellect (if you pardon this metaphor).

6.     Nobel illuminations. Peter Higgs (pictured) was prominent among the physicists who in 1964 proposed the concept of a new elementary particle that became known as the Higgs boson, in the Standard Model of Physics. It took many decades and complex experimental facilities to actually find this elusive particle that had only been dreamt of in the imaginations of Higgs and a few other physicists long before it was actually observed. Higgs won the Nobel Prize in Physics for this work back in December, 2013. This year’s physics award went to Isamu Akasaki, Hiroshi Amano, and Shuji Nakamura, who recognized that gallium nitride in a laser could produce a blue LED light and by adding aluminum and indium they were the first to create efficient white LED light. One winner of this year’s Nobel Chemistry Award was Eric Betzig, who had grown up in Ann Arbor and is now at the Howard Hughes Janelia Campus in Virginia. His work has taken optical microscopy to the nanometer and biologic real-time levels of living tissues. Illumination of different kind comes from another Nobelist, the great Peruvian writer Mario Vargas Llosa, in the extraordinary Nobel Lecture “In Praise of Reading and Fiction,” when he won the 2010 Prize for Literature. Recalling his childhood and the impact of learning to read, he wrote: “Reading changed dreams into life and life into dreams and placed the universe of literature within the reach of the boy I once was.” The social instability of his native Peru made the matter of politics acutely relevant to his life as he noted in his lecture: “Without fictions we would be less aware of the importance of freedom in making life livable, of the hell it turns into when it is trampled underfoot by a tyrant, an ideology, or a religion … Good literature erects bridges between different peoples, and by having us enjoy, suffer, or feel surprise, unites us beneath the languages, beliefs, habits, customs, and prejudices that separate us.” In less than 40 pages, Vargas Llosa makes an eloquent case for his compelling belief that language and the stories and literature it produced humanized us humans and allowed us to invent the “autonomous individual,” disengaged from tribes, clans, and nations, and capable of devising science, art, and freedom. [Mario Vargas Llosa. In Praise of Reading and Fiction. Transl. E. Grossman. Farrar, Strauss and Giroux. NY. 2011]

[Vargas Llosa]

7.     Ouroboros. The ouroboros is an ancient symbol depicting the place of the human element in space and time. The figure of a serpent devouring its own tail has been labeled by its Greek term ouroboros, which had piqued my curiosity when I watched the TED talk of Martin Rees (mentioned here in Matula Thoughts last month) and then the word came up again in Julian Wan’s engaging talk at the Nesbit Society meeting – “Why we won’t cure cancer in our lifetime.” The roots of the symbol trace back in turn to ancient Egypt, Plato, Norse mythology, alchemy, and Carl Jung. The prominent German chemist August Kekulé (1829-1896) attributed his discovery of the structure of benzene to a eureka moment in 1872 when he dozed off in front of the fireplace and saw the elements of the benzene ring assembling themselves in an ouroboros. I asked our illustrator, David Heskett, to render a modern version, urologically centric, that I enclose herein. Viewing the figure of snake,  or dragon in some representations,  from the tiniest beginning in a counterclockwise fashion, you can imagine the progression in scale from somewhere around the Higgs Boson with the tiniest bits of energy and matter developing into the cosmos at a far grander scale with us mere humans near the middle.

[Ouroboros per David Heskett]

8.     Data and decisions. At our recent HSR symposium, the role of “big data” in health care was covered thoroughly by an excellent cadre of speakers. We still have CDs available if you are interested. At our Health Services Research Symposium our friend and UMMS alumnus Jack Peirce had insightful questions for the speakers at every session. Jack (shown above) has had a long interest in medical decision-making and wrote a compelling article on the topic around 20 years ago and the matter of deciphering useful information from all the noise around us. His paper described how in the early days of radar technology during WWII, radar operators struggled to detect meaningful signal from the noise. This led to the “receiver operating characteristic (ROC) curve” later introduced into clinical medicine in the 1960’s by Lusted. [Peirce JC, Cornell RG. Integrating stratum-specific likelihood ratios with the analysis of ROC curves. In Medical Decision Making. Hanley & Belfus, Inc. Philadelphia. 1993.] I came to know Jack through our Nesbit Society member Clair Cox, of the same medical school class (UMMS 1958) and former Chair of Urology at the University of Tennessee. Clair, by the way, couldn’t make it for this year’s Nesbit meeting but had come to Ann Arbor with his wife Clarice, son Kevin, and grandson Ben for the Minnesota game, wherein we glumly received a negative signal of a 30 to 14 defeat.

9.    Medicine’s essential transactions. This month we begin anew the important annual cycle of interviews for residency candidates. The medical students we pick will finish our urology residency program in 2020 and their fellowships in 2022, 2023, or 2024. That is, to say, they will begin practicing urology on their own around 10 years from now. The world and the world of health care will be different for them than it is today, although the central dynamic of health care, the doctor-patient relationship, will probably be much the same. A patient will ask a doctor (or other provider) to take responsibility for their health care. Michigan’s late and great physiologist Horace Davenport characterized this work as “the service station of life.” This has been an essential transaction for millennia, and is not likely to disappear or be replaced by data and computers. My point of view as a patient is probably not much different than that of any other patient (and we are all patients one way or another, at one time or another); as a patient I want expertise, kindness, and convenience – in that order, although I want all three. Nonetheless aspects and expectations of the essential transaction are changing. We must find ways to be better, safer, and leaner in the delivery of health care. Now we might use the terms “healthcare” instead of medicine and “healthcare provider” instead of doctor. Technology has become a dominating force in modern medicine. Furthermore, some aspects of healthcare are easily commoditized and do not need that essential transaction between a professional and a patient. The role of the computer in healthcare is rising – but computers even with artificial intelligence (AI) are unlikely to have “minds” that can truly understand wisdom. That is, like our new smart phones, they may act smartly but they are not conscious. AI may yield smartness and decisiveness based on analysis of data, but not wisdom and truth.

10.    Noise. This term is most often employed for its acoustic meaning, specifically with reference to “unwanted sounds.” Yet noise is not necessarily unwanted, we have white noise or comfort noise. Noise can in fact describe any sound. Noise is not only acoustic, it may also be optical, describing a poor quality in digital photography. The valuation of a sound as wanted or unwanted is a reflection of our opinions, and it is not difficult to understand how even an unwanted sound or noise can be useful in some way. More fundamentally noise connotes any perturbation of time and space. A search for wisdom and truth must begin, therefore, with a consideration of noise because information is noise that makes some sense to us. Information that conveys useful information about the world is called knowledge. Models, constructs of reality built from knowledge, are described by our colleague Scott Page as logically consistent metaphors. Reality cannot be understood perfectly by any single model, but a number of models will likely give a closer view of the truth. Thus the Standard Model of Physics may help us understand space and time but not Butch Cassidy, Peruvian politics, or renal carcinoma. As better models are constructed, networks of models, although fraught with bigger data, theoretically will offer an even more realistic vision of reality. It is the perpetual optimism of the human condition that these intellectual efforts will bring us to the wisdom and truth our species seems to crave.

11.    Courtship. As the educational year for our residents nears the half way mark we are already well into the process of finding their successors for internship or the PGY 1 year (first postgraduate year after medical school). Selecting from 340 applicants we will interview about 60 and just last week interviewed the first 32 over two days and one dinner evening at Gary Faerber and Kathy Cooney’s home. Each year we see higher and higher exam scores and this year pushed the upper limits even higher. These were astonishing individuals of diverse life experiences, some incredible personal challenges, widely varied educational backgrounds, and language capabilities from Mandarin, Russian, Cantonese, Spanish, Sign, Arabic, or Gujarati. Practically any of them would be superb residents here at Michigan but we can only have four. The interview process (expensive for them and expensive for us) allows these fourth year medical students to evaluate and rank us just as we do them, so this is a process of sophisticated courtship. Their selections and ours determine the career-defining stage of their education so while this process is very important to our department of urology, the process is absolutely critical to each of the candidates for a position in our class of 2020.

[Ted Lee PGY 1 and candidates at breakfast the day after interviews]

12.    Final thoughts. I try to discipline Matula Thoughts to 10 items, but today couldn’t bear to leave out the residency applicants we saw last week. These individuals (and I mean everyone who interviewed with us last week) are the “smart creatives” who will define the next generation of urology and the world around urology. The term “smart creatives” comes from another book I just read, and in fact discussed with the applicants. Written by Google’s former CEO Eric Schmidt and VP for Products Jonathan Rosenberg the book is called How Google Works. It is quite informative about the unique Google culture and well worth your attention. I took much from it but have only one main objection and that came as I read the conclusion in which the authors offer their absolute faith that information (data) will solve virtually all of the big problems facing mankind. I believe that data can help solve many problems, but data is most likely to help find the low-hanging fruits of technology that will benefit largely those of us on the right side of the upper end of the bi-modal economic distribution of mankind’s wealth. However the essential needs of mankind, the loftier aspirations will not, in my opinion, be so smugly solved. The issues of poverty, human rights, universal education, safety, global disaster, food security, climate change, war, epidemics, or mankind’s penchant for extremism and other “isms” are a few examples. We could add meteoric calamity to the list since Ensisheim’s big brother is likely to show up some day. Until we achieve some multi-continental governance that is wise, fair, and enforceable no amount of data or technology will create a world where diverse people can live safely, happily, and creatively to build an even better world for their children. Google may help, but it is hardly going to get us to the answer. Although, by the way, why can’t Google build us a decent electronic medical record that could truly improve patient care, “meaningful use”, and also the lives and quality of work of health care workers. After all, no one else has come anywhere close (ok – maybe our own CareWeb and CCC forms of electronic medical records came close, but federal regulations forced us to discard them). Enough said for now.

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

David A. Bloom

Matula Thoughts September 5, 2014

Michigan Urology Family

Seasons, health care goals, required reading, truth & proverbs.

1. The writer Gertrude Stein once said: “A rose is a rose is a rose.” This summer has been replete with many roses but, with all due respect to Stein, if you look closely enough none is exactly the same as another. An equivalent generalization might be: “A year is a year is a year.” Although we begin the Earth calendar year of 12 months and 365 plus days on January 1 we also begin it at other times for specific purposes. Our fiscal year as well as the residency-training year start on July 1. The medical school students’ first year began just last month on August 3 with the White Coat Ceremony on a Sunday afternoon in Hill Auditorium. In the presence of their families and friends each student crossed the stage, announced his or her name, and received a short white coat and a stethoscope. We have been organizing the stethoscope presentations for the past ten years as a gift from the clinical departments and several benefactors in our community to the tune of more than $250,000 over the decade. Just as the stethoscope is a symbol for the practice of medicine, their presentation to the incoming medical students is a symbol of commitment of the clinical teachers and community to the education of the next generation of physicians. As the new students settle into their routines yet another type of year, the university academic year, began a few days ago on September 1 and with it now underway we find Quentin Clemens, Khaled Hafez, Brent Hollenbeck, and John Park promoted to professor and Jeff Montgomery to associate professor. These men are the best of the best in their areas of practice and scholarship. We welcome two new colleagues to our faculty: Jim Dupree who completed a Male Reproductive Medicine and Surgery Fellowship at Baylor College of Medicine and Nick Warner who finished a Trauma Reconstructive Fellowship at the Detroit Medical Center.

[White Coat Ceremony Hill Auditorium August 3, 2014. The cloaking of first year medical student Andrew Kozminski by his father Mike (Nesbit 1989) and brothers Michael (PGY 5) and David (UMMS class of 2016).]

2. The White Coat Ceremony marks the starting point for a life of medical education. Medical school graduation, usually four years later, is a major milestone along the pathway of lifelong learning that necessarily follows. Completion of residency training and its fellowship extensions are other occasions for celebration, these periods typically exceeding the four years of medical school. Specialty board certification a few years after formal training ends is an essential checkpoint for independent practice of urology, but now we find the concepts of “lifelong certification” and “re-certification” have turned into systematic “maintenance of certification.” You might question the point of all this – what are the goals of medical education, residency training, and certification in the first place? The answer to these questions requires historical framing and a belief in the balance of public policy and the right of a profession to set its own standards. Ultimately, however, they beg larger questions: what are the goals of healthcare and how do we best accomplish them? We touched on these issues briefly last month, considering healthcare metaphorically as necessary “attendence at the service stations of life”, to use Horace Davenport’s metaphor. The questions just raised are deep and essential – not just for those of us engaged in the processes of medical education, healthcare, and research. These issues are central to our work and lives, and they compel much of the attention of this communication we call “Matula Thoughts.” As a basis for further considerations I’d like to call your attention to a new book by Danielle Allen, called Our Declaration. This should be required reading for everyone. It is a deep, but very smooth dive into the 1337 words of the Declaration of Independence. Professor Allen will give you a new understanding of the ideas of liberty and equality relating directly to our immediate daily concerns of health care, professional standards, and public policy. The book came out right around Independence Day and I only just recently finished it, but will be coming back to it again in future “Matula Thoughts.”

3. Ed Tank (Nesbit 1971) is a great role model for me with the idea of keeping a book, a real book, on your person when travelling about so you can always have something to read worthy of your time. I recall him in years past carrying around substantial hard-bound volumes to read at spare moments. My wife Martha, on the other hand, carries an iPad with its library of books weighing only a couple of ounces, but my preference is for slim paperbacks or little hard cover books that fit into a sport coat pocket. Coming back from the AUA in Orlando, with a side trip to Memphis, I carried Tolstoy’s The Death of Ivan Ilych. This little paperback is part of a series called The Art of the Novella by Melville House. The book, with its new translation by Ian Dreiblatt, caught my eye at our new bookstore, Literati, in downtown Ann Arbor so I picked it up and took it along on a few previous trips, until its time to be read came up on that journey.                                           [Ed  & Rosalie Tank, with the late Lowell King on right]

  [Literati Bookstore, Ann Arbor]

4. The story is simple. Ivan Ilych, a fictional 45-year old successful Russian attorney died in St. Petersburg on February 4, 1882. Discovering that fact in the newspaper the next day at work, his colleagues commented on Ivan’s demise with varying degrees of sympathy. Tolstoy then recounts the life of the man, gradually revealing ironies of Ivan Ilych’s career, marriage, and friendships, all viewed at first impression as conventionally successful. The illness that caused his death dated to an injury sustained two years earlier when Ivan Ilych struck his side as he fell off a ladder. He had been trying, at the moment, “to show the uncomprehending upholsterer how he wanted the drapes hung” in his stylish new home. Dull discomfort in the left flank gradually increased after the injury, leading to pain. Consulting physicians offered varying opinions and “a urine test” was mentioned, although Tolstoy gave no results. Malaise, cachexia, and intolerable pain ensued over the next two years. Finally Ivan Ilych became confined to his couch for weeks until his end came. Whether intended or not, this story is an accurate and brutal depiction of death from an untreated kidney cancer that had likely ruptured.

5. Tolstoy (1828-1910) was either anatomically confused or mischievous in explaining how the physicians considered Ivan Ilych’s illness a matter of the appendix or kidney, even though the left side was clearly specified. The term “floating kidney” was added to the diagnostic mix. We must take into account the state of medical knowledge and urology in particular during the later years of Tolstoy’s life. Emotionally, however, Tolstoy had perfect pitch. His portrayal of physical deterioration, the anguish of impeding death, as well as the complex and often insincere responses of family and friends, was terribly convincing. The gradual unraveling of Ivan Ilych’s pretension, self-delusion, and dignity embittered his final days as he recoiled from attempted acts of kindness. Ivan Ilych offered a number of Joycean internal riffs, but produced no grand Shakespearean soliloquies although he surely came to question who he was, indeed he wondered “what he did wrong” to incur his horrible fate. He tortured himself in the final weeks searching his memories to comprehend how the life that he had believed so sweet could turn into an irreversible nightmare, until he suddenly realized: “There is no explanation!” His story, though, is an exaggerated version of everyone’s story. Who we are, to ourselves and to those around us, is a story of many versions. From Ivan Ilych we see that even who we think we are is, to some degree, a self-delusion.

6. Tolstoy targeted our imagined personal exceptionality While acknowledging that we know all men are mortal and that each of us is a member of mankind sharing the same fate, we nonetheless individually carry the delusion through most of our lives that the mortality proposition doesn’t quite include “me.” Our personal exceptionality is both true and not true. While we each are unique and indelible to ourselves, none of us is uniquely exempt from that ultimate prescription of mortality. The same holds true for Stein’s rose. How Tolstoy came to the beliefs he had in 1886, at age 58 when he wrote the story of Ivan Ilych, can perhaps be discovered though his semi-autobiographical fiction and the serious biographical work that has accumulated. Interestingly, if you go to the web site worldcat.org/identities/Iccn-n79-68416/ you find a publication time line that shows the yearly volume of publications by Tolstoy and about Tolstoy. Notably, the two categories are approaching parity, indicating that people today read almost as much about him as by him. For a student described by his teachers as “both unable and unwilling to learn” Tolstoy turned out pretty well as a mature literary figure, although using our modern vocabulary of political correctness he would be branded as “disruptive.” This adjective is widely overused today in its negative connotation, even though we recognize value to “disruption” in the scientific, technological, and business worlds. Politically and culturally, Tolstoy’s disruptions improved mankind and his reach is still growing. If you re-read Ivan Ilych that reach will grow a little more, and so might you. Were Tolstoy still alive, he would have celebrated his 186^th birthday last week.

[Tolstoy, disruptive author]

[worldcat.org/identities/Iccn-n79-68416/]

7. The chances for a patient with kidney cancer have improved vastly since the fictional death of Ivan Ilych. One hundred years later by the time of my residency and early years of practice, the miracles of diagnostic imaging, anesthesia, plus efficacious operative techniques in the hands of well-trained surgeons the outlook for patients with kidney cancer had improved markedly, yet another quantum leap was soon to follow. As junior staff person at Walter Reed Army Medical Center in the early 1980s I met another young urologist, Marston Linehan, who had just taken the urology position at the National Cancer Institute. In the years since then he has practically written the book on kidney cancer, elucidating the various metabolic pathways that cause it, classifying its genetic types, and discovering targeted treatments. I have several close friends alive and well today due to the combination of Marston’s discoveries and superb surgeons. I recently wrote to Marston about Ivan Ilych and found that he, of course, had read it years ago. The book is short and well worth re-reading even if you too had encountered it years ago. It slips easily into your pocket, or you can go the route of Kindles, smart phones, and iPads if they are your preferred media tools. Marston Linehan, M.D. is still Chief of Urologic Surgery and the Urologic Oncology Branch, Center for Cancer Research, at the National Cancer Institute, National Institutes of Health in Bethesda, Maryland. He and his team identified the critical genes responsible for von Hippel-Lindau Disease, clear cell renal carcinoma, hereditary papillary renal carcinoma, chromophobe renal carcinoma, among others. Marston’s work has led to understanding of the genetic events associated with the initiation and progression of urologic malignancies thereby enabling successful therapeutic strategies. He visited us here in Ann Arbor last autumn.

[Marston Linehan]

8. We conveniently divide writing into fiction and nonfiction. The boundary is important to us as physicians and scientists, because truth is a presumption of our work. Trust underpins everything in medicine and science. When dishonesty, in the form of false reporting, lies, or plagiarism are discovered trust is lost. The adage “trust, but verify” is useful although in the helter skelter of clinical work or the fast-moving world of modern scholarship, every detail cannot be quickly verified. When a colleague tells you that a patient’s creatinine in 1.0, you trust that report and make assumptions and critical decisions based on that “fact.” Honesty is essential, whereas accuracy is an aspirational trait that must be honed. Don Coffey, great role model of critical thinking for many of us, carried the idea of truth a step further when he said: “You need to know the difference between facts and true facts.” Tolerant of human frailty, but evangelical regarding the pursuit of excellence, Don also once said to me “Anybody can make a mistake, but it shouldn’t become ‘a way of life.” The rich vocabulary of integrity indicates its centrality to the human condition. An old proverb says “truth is the daughter of time.” Lincoln said: “No man has a good enough memory to be a successful liar.” Frankfurt, the esteemed philosopher at Princeton, wrote: “Any society that manages to be even minimally functional must have, it seems to me, a robust appreciation of the endlessly protean utility of truth.” Furthermore he said: “It seems even more clear to me that higher levels of civilization must depend even more heavily on a conscientious respect for the importance of honesty and clarity in reporting the facts, and a stubborn concern for accuracy in determining what the facts are.” I have been astonished on rare occasions to find blatant plagiarism in my role as a journal reviewer from people who clearly “should know better.” How I deal publically with these rare birds in academia has been a dilemma. Do I call them out, do I attempt to educate them, or do I remain within the comfortable anonymity of the peer review process? What should be my obligations towards honoring someone else’s dishonesty? On the other hand, when does academic sloppiness slip into convenient plagiarism? I don’t have good answers for these questions.

[Don Coffey, Professor of Urology, Johns Hopkins]

9. Scientists cannot be dismissive of fiction, however, because good fiction is an exercise of human imagination that illuminates a “real world” of facts and true facts. This brings us to the almost paradoxical consideration that there can be truth in fiction, insofar as a story is authentic. The world imagined in a writer’s mind, stripped clean of distracting elements and illuminated with precision, may give a more precise picture of reality than might otherwise be observed in the “real world.” This is the beauty and utility of story-telling. Ivan Ilych serves us well, illustrating the rough natural history of unattended kidney cancer, the definition of a “well-lived” life, and ultimately the individual comprehension and social indignities of death. Yet just as reality can be better understood through fiction, fiction can be double-edged and distort reality. This thought brings us to the uncomfortable question that naturally arises from Ivan Ilych’s story: When does belief in our own narrative stray into fiction? The fictional death of Ivan Ilych is a reasonably authentic depiction not only for a death from uncontrolled renal cell carcinoma, but more so for an end of life in general. In the grand scheme of life, a death is a death is a death. Yet death is usually only a footnote to the unique opportunities and accomplishments of each life, with the roses enjoyed along the way. Our faculty and their teams in the Uro-Oncology division (three of whom were just promoted academically as mentioned earlier) deal with death more than the rest of us in the department, they being more so attendants at the later service stations of life. Yet each of us, at the personal level, will stop at those stations. The most important estate each of us leaves behind, after that last station, aside from family and friends, will ultimately be our work and our integrity. After all, while roses are seasonal and variable, truth is the legitimate daughter of time.

   [Rose garden of Bob and Mary Lichty, Waterloo, Iowa]

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

David Bloom

Matula Thoughts March 7, 2014
Michigan Urology Family
Curiosity, polar thoughts, cats, dogs, & the human element

Amundsen at South Pole

Amundsen dressed for polar vortices

1. The days of winter are counting down now that March is here. It has been a curious season of drastic shifts in weather, highlighted by the Polar Vortex. Last month in “Matula Thoughts” we touched on Norse mythology and today want to include some Norse reality, specifically Roald Amundsen, the polar explorer and man of many firsts. Born as a fourth son in 1872 to a family of ship owners and captains in Borge, in the United Kingdoms of Sweden and Norway, his mother hoped for him to avoid the family business. As a young man he promised her he would become a physician, but after she died when he was 21 he quit his studies and went to sea. He made his mark early and became first mate on the Belgica in the first expedition to winter in Antarctica (winter of 1898-99). He then led the first expedition to traverse Canada’s Northwest Passage (1903-1906). Arriving in Nome in 1906 Amundsen learned that Norway had just become independent of Sweden and he sent the new Norwegian King a patriotic note regarding the expedition’s success. Amundsen’s 1911 Antarctic expedition was the first to reach the South Pole (but lacking satellite phone technology the world didn’t learn of the fact until this very day March 7, 1912). His 1926 Arctic expedition was the first to indisputably reach the North Pole. Earlier claims from others were controversial, but the 16 man-expedition with Amundsen as leader and navigator was the first as their hydrogen-filled semi-rigid airship, the Norge, on May 12, 1926 flew directly over the North Pole. Amundsen disappeared in an Arctic rescue mission in June 1928. One can only marvel at the Norse Human Element and speculate what Amundsen’s curiosity might have elicited had he focused on medicine.
   

   Nansen the cat

   

   Nansen the Nobel laureate

2. Curiosity did kill the cat, by the way. Nansen was the name of the ship’s cat on the Belgica in Amundsen’s Antarctic Expedition. The cat, named for Fridjof Nansen, died on June 22, 1898 while the Belgica was wedged in pack ice for nearly a year. The mascot’s namesake, Nansen the human (1861-1930), was a great athlete, biologist, explorer, and Nobel Peace Prize Laureate. As a prominent citizen he was a strong advocate for the independence of Norway. The cat had a lot to live up to. [a. Cat drawing by his owner, cabin boy and assistant zoologist Johan Koren; b. Fridjof Nansen, Nobel laureate.]

   

   

3. Last month we mentioned some elements listed on the periodic table, including thorium and radium, and now want to continue that theme with bromine and chlorine. Although not radioactive, these halogens are corrosive and toxic (bromine) and strongly oxidizing (chlorine). The fact that elements of the periodic table have somehow assembled throughout the universe to produce such things as H₂O, NaCl, larger compounds, creatures like Nansen’s cat and then the human brain is perpetually astonishing. This thought makes me marvel, as well, at the advertising ingenuity of Dow Chemical Company that developed a campaign with the powerful idea of the “human element.”
4. Herbert Dow was born February 26, 1866) in Canada, and after early childhood in Connecticut, he grew up in Cleveland, where he attended the Case School of Applied Science. His interest in chemistry led to the study of underground brines, and his discovery that groundwaters in Canton, Ohio and Midland, Michigan were unusually rich in bromine, an important ingredient in medicines and the merging photography business. A year after graduation he obtained a patent for a process to extract bromine and expanded his electrolysis methods to produce chlorine and other products. In 1897 he founded the Dow Chemical Company in Midland and the company stands today as one of the great global businesses. Dow died in 1930 and his widow Grace in 1936 established the Herbert H. and Grace A. Dow Foundation. You may have seen the Dow diamond logo last month as one of the partners in the Olympic & Paralympic Games.
5. Our Urology Department at the University of Michigan owes a large debt to the Dow name, for it was the Herbert H. and Grace A. Dow Foundation that delivered us from the trailer. By this I mean our fledging Health Services Research (HSR) Division, created by Jim Montie and inaugurated by John Wei started out in a part (709 sq. ft.) of the “temporary” trailer adjacent to our old Women’s Hospital. The trailer still stands, just like the fabled Hewlett-Packard Garage in Palo Alto (that too has relevance to the University of Michigan Medical School).
   

   Our fabled HSR trailer

   The Dow Foundation generosity allowed our HSR Division to move into much more favorable space in the Martin Corporation’s Michigan House (4600 sq. ft.). This beautiful endowment propelled our Dow HSR Division into the intellectual stratosphere, educating the leaders and best of the next generation of educators, investigators, and clinicians in urology. Success creates a new set of issues and under the successive leadership of Brent Hollenbeck our Dow HSR Division outgrew even that ample space in the Michigan House, causing recent relocation to more spacious room for growth in Building 16 at our North Campus Research Complex (NCRC).

   

   Jim Montie

   

   John Wei

6. David Miller now heads our Dow HSR Division, leading a talented team to ask and answer important questions related to how we deliver urological care. What is the “right” treatment for an individual patient? When and where are the optimal times and places for treatments? How should society allocate costs of urologic healthcare? Our patterns of practice must be dissected and rebuilt even as health care practice is changing in front of our eyes. The Dow HSR has stimulated a cadre of superb students, residents, fellows, and faculty who are asking good questions and finding important answers. Their work has attracted serious attention of policy makers, scientists, and care providers.
   

   Brent Hollenbeck
   Former HSR Director

7. David Miller,
   Current HSR Director

   A number of years ago The Lancet had a curious Editorial entitled “What is the point of surgery?” and that question has stuck in my mind. [The Lancet 376:1025, 2010] I put the article in a folder of “curious thoughts” and the following year added another paper to it: “What patients really want from health care” by Allan Detsky. [JAMA 306:2500, 2011] Detsky considered three levels of priority. The first level listed 9 items that the public wants most: restoring health when ill, timeliness, kindness, hope & certainty, the “three C’s” of continuity/choice/coordination, private room, no out of pocket costs, the best medicine, and finally medications & surgery. The second level priorities were; efficiency, aggregate-level statistics, equity, and to some extent transparency of conflict of interest. The lowest level of priority for patients consisted of two things: real cost and percent gap of GNP devoted to health care. Questions like these may once have seemed rude and pointless to proud ivory towers in academia, but today they are exactly what the public wants to know. Academic medical teams can answer these better than politicians and pundits. While Detsky among others can pose important questions like he did, the best answers and solutions will come from groups such our Dow HSR unit.

8. Italian engineer Umberto Nobile, as a young man became an enthusiast of semi-rigid airships and after a period of work in Akron, Ohio with Goodyear, he returned to Italy to build a new airship. Hearing of this Amundsen developed a collaboration with Nobile to find the North Pole, naming his hydrogen filled airship the Norge. The actual flyover, however, turned into a “circus wagon in the sky” according to Amundsen. Nobile had brought his dog Titina, 12-pound Fox Terrier, aboard as ship’s mascot. Nobile had rescued the starving puppy on a street in Rome only the year before. Amundsen was furious that his Italian partner had brought the dog along since the airship quarters were so cramped. Tensions increased when Amundsen noticed as the American, Italian, and Norwegian flags were dropped on the pole, the Italian flag was noticeably larger than the others. Although the expedition fueled national jealousies, it was the first to actually find the pole. Other expeditions that claimed the pole lacked navigational accuracy, and Admiral Richard Byrd’s alleged “fly-over” in a Fokker F-VII, the Josephine Ford (named for Edsel’s daughter) on May 9, 1926 turned out to be inaccurate, with falsification of navigational journal data. Titina proved to be a worthy companion for the grumpy explorers on the Norge and helped the human element remain moderately human throughout the difficult days of the journey.
9. It’s difficult to escape the power of Dow’s metaphor of the human element. Companionship, of any kind – even canine or feline – maximizes the human element. Whatever forces (selfishness or selflessness) propel human curiosity to explore, innovate, and discover the net results have served our species in aggregate far more than serving the individuals. Amundsen died at 55 disappearing in the Arctic while flying on a rescue mission. The mission was to recover survivors of the crash on sea ice of the, Italia, another airship of Nobile who was on board with his companion Titina. On May 25, 1928 after a series of mishaps the Italia lost altitude and hit sea ice. The gondola smashed open, dumping supplies, nine personnel including Nobile, and Titina. Relieved of the weight, the airship rose with 6 crew still on board, drifted away and was never seen again. The survivors on the ice radioed for help. Several rescue missions set out to recover the crew over the ensuing weeks, but it was Amundsen’s group on a Latham 47 flying boat that disappeared on June 18. The Italia survivors were spotted by other rescuers on June 20, and saved in turns between June 23 and July 14. Nobile, Titan, and eight other crew members survived. Curiosity obviously has its downsides, and perhaps dogs are more durable than cats in polar explorations, but the future depends on human curiosity and innovation. Those of us in urological practice, science, and health services research have the advantage of extending our curiosity in safer and warmer environments.
10. What’s next in urology? What’s the next North, South Pole, or Midland brine to be discovered for Uro-Oncology, Pediatric Urology, Neuropelvic Reconstructive Urology, Sexual Reproductive Urology, Health Services Research, or Urology in general?  Michigan Urology has been a key player in pushing back many urologic frontiers since the time Hugh Cabot came to town in 1919 and placed Ann Arbor on the center stage of genitourinary surgical practice, research, and education. While it is inspiring to understand the history of one’s institution, every new generation, each new faculty cohort, each new residency and fellowship class must start anew from the baseline of knowledge and skills they find at entry to the profession. The spirit of exploration can get dampened by the necessities of every day’s work, but every generation has its leaders and best in whom curiosity is not just retained, but even energized by the annoyance of their confinements in their time, geography, and knowledge.

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

David Bloom

1. A new January and 2014 are at hand and given general and personal good fortune for you and I, along with the Urology Department, a good year lies ahead in spite of great change swirling around us. The year began with the thrilling Winter Hockey Classic in Michigan Stadium between the Red Wings and Maples Leafs. The same day we saw health care extended to millions of “uninsured” and elimination of the odious pre-existing illness restrictions and life-time limits on benefits. Few can deny these important public goods, but the collateral damage of the legislative and regulatory context of these changes is significant. While we cannot cling to the past, not all that is new turns out for the greater good. Rather than massive shifts in the superstructures of health care, we should recapitulate the Darwinian methodology of creating optimum adaptive phenotypes for the future. That is, we need to create new (experimental) clinical, educational, and research models in the hope that some of these might best fit the immediate but unexpected environments of tomorrow.

2. The 16th century Spanish writer, Miguel de Cervantes Saavedra, said in his book Don Quixote: “To imagine that things in life are always to remain as they are is to indulge in an idle dream.” [Part 2 Chapter LIII] He mischievously added: “It would appear, rather, that everything moves in a circle, that is to say, around and around: spring follows summer, summer the harvest season, harvest autumn, autumn winter, and winter spring; and thus does time continue to turn like a never-ceasing wheel.” Cervantes surely knew that as seasons cycled regularly, even in his retrograde version, no two successive ones were identical.

3. Change was exemplified on this particular day (January 3) in many years past. In 1496 on January 3, for example, Leonardo tested a flying machine, but lacking an aluminum internal combustion engine, the deep mechanical expertise of the Wright brothers, and the winds of the outer banks he didn’t break the barrier of sustained heavier than air flight. Still, he was far ahead of his time and technology. Our national geography changed on this day in 1823 when Stephen Austin received a grant of land in Texas from Mexico and in 1959 when Alaska became the 49th state. And who could have predicted on this day in 1977 when Apple Computers was incorporated that the whimsically-named company would become one of the largest companies in the world (currently #15 by Forbes listing for 2013 and #1 by market capitalization in 2013 Q1 and Q3 – dropping to #2 in the second quarter of the year). We should also keep in mind that 2014 is a full century after the start of the ill-fated War intended to end all wars. Change is inexorable and although not all change is good, we need to not only survive change, but come out better at the end of it.

4. Last month’s story of the Halifax disaster elicited a comment from my friend and colleague David Diamond of Boston Children’s Hospital who noted that every year the City of Halifax sends his Children’s Hospital a splendid Christmas tree in thanks for the outpouring of support and volunteers that rushed to Nova Scotia after the horrendous explosion.

5. With Stu Wolf as Acting Chair of the Urology Department for the first quarter of 2014 we repeat last year’s very successful experiment with John Wei in charge. One of the fruits of my mini-sabbatical labor then was our departmental A3 and its derivative “baby A3s” that have benefited our departmental thinking and operations. John did a superb job in the front office and brought great ideas and analyses to the department, continuing to provide leadership and clear thinking. His quarter at the helm changed him and benefitted our department. Stu will likewise bring valuable new insights and ideas to our departmental table.  John Wei has taken over the weekly production of “What’s New” except for the larger broadcast on the first Friday of the month that Stu will produce as chair. I missed this ritual last year, so I will independently keep up the “Matula Thoughts” Blog. You will thus have two fabulous reading options for that first weekend of each month this winter. If you must choose just one, I recommend picking the “What’s New” of Stuart.

6.    I started to read Don Quixote a number of years ago out of curiosity and what I felt to be a need to be familiar with key parts of our literary heritage. My sally into the canon didn’t take me to the very end of the story, as the adventures of the deluded knight-errant, while initially amusing, became tedious. In short order the wanderings of the Don, Sancho, and Rocinante became supplanted by Urology Department promotion letters, recruitment, retentions, committees, Faculty Group Practice, patient care, and other day-to-day matters. Accordingly, the book (Modern Library, Samuel Putnam translation, 1998, over 1200 pages) found its way back to my shelves. (Picture: Title page first edition of Don Quixote Part 1, 1605)  Actually titled The Ingenious Gentleman Don Quixote of La Mancha, the text was a foundational work of modern Western literature. Published in two parts by Spanish author Miguel de Cervantes Saavedra in 1605 and 1615, the book tells the story of Alonso Quijano, an older member of the nobility who becomes so brainwashed by chivalric stories (the novels of his era) that he sets out to revive chivalry. The term chivalry comes from the obvious French word meaning “horse soldiery” and carrying with it characteristics of gallantry, training, service, and knightly virtues including courtesy, love, and honor. The Knight’s Code of Chivalry was a moral system requiring knights to protect those who were incapable of protecting themselves. These fundamental values emerged during the earliest human existences of small bands of hunters and gatherers. Over ensuing millennia these values were incorporated for larger society by religions. The Spanish and Portuguese knights’ codes of Cervantes’s era offered laymen’s versions that simultaneously supported the church and translated those values into the special obligations of a “profession.”

7. With the enlightenment it became clear (“self-evident” as said in the founding documents of the USA) to many thinkers and occasional leaders that a moral system with values such as those in the knights’ code was a duty of the state or government. Our Declaration of Independence, Constitution, and Bill of Rights took over from religions, knights, and philosophers. The essential values of life, liberty, the pursuit of happiness, and equality were stated well and eloquently in those documents, although our national execution has been imperfect and the prime fault at the start was the persistence of human slavery that took a civil war and a further century of countless injustices to start to set straight, although it still persists in this world. Social justice is elusive. Health care is intrinsic to any reasonable modern chivalric code. Our dilemma is how to get it right, how to find the right mix of federal, state, professional, and private sector contributions even as rapidly evolving technology heightens the complexity and costs of health care. The private sector of business and the health care professions together cannot fill all of the health care needs of the people of a nation. The government alone is also woefully inadequate. Furthermore an insurance paradigm makes no sense either as the dominant methodology of providing health care to a nation. Hundreds of billions of dollars, complex legislation/regulation, and incalculable political rhetoric are only making matters worse with a good solution further away from today.

8.  Last October I mentioned an amazing crayon drawing made by a little girl as her sister sat on a doctor’s examining table. In the picture the patient, the mother and little baby on her lap, and the 7-year old artist were regarding the viewer in the best tradition of Vermeer. In contrast, the physician sat off to the left side, intently typing on a keyboard and looking at the computer screen. The accompanying article in JAMA was written by Elizabeth Toll, at Brown University, and the copyright for the illustration listed Dr. Tom Murphy (likely the physician so-depicted).  Both he and Dr. Toll kindly gave me permission to utilize the picture that I’ll show again. [The cost of technology. Toll. JAMA 307:2497-2498, 2012] The illustration shows how the electronic medical record, mandated in swift deployment by the unfortunate HITECH Act, has become for many of us, a surrogate for the patient. Technology has gone beyond enabling to distorting the practice of medicine. This is just one more threat to the idea of medical practice as a profession. Many social and regulatory pressures are forcing the commoditization of medical practice, with a misguided belief that technology will solve the problems. The ridiculous mandated complexity of ICD-10 is another related matter (see the article in New York Times Business Day by Andrew Pollack December 30, 2013” “Who knows the code for injury by Orca?”).

9. Medical practice is just one part of health care and even that part consists of many goods and services. Some parts of health care are best dealt with by society as commodities. For example, perinatal care, immunizations and dental cleaning. These all serve the public interest and can be delivered economically by a number of means. They can be delivered efficiently as public goods at free clinics. They can also be delivered very conveniently at drug stores, grocery stores, or in smartly-designed health care facilities (how I wish we were so “smartly-designed” at the University of Michigan). They can also be provided in professional offices. In an ideal free society, people generally have a choice as where to obtain these commodities, but in any case when people don’t have a reasonable choice the important commodities must somehow be provided.

10. Other professional activities are more complex, such as the sorting out of a specific health problem and finding a remedy. The remedy itself may require a complex orchestration of personnel and a complex performance of the manual (and now robotic) arts of surgery. A professional doctor-patient relationship lies at the heart of most of these amazing feats of modern healthcare. Even more complex, but something modern healthcare has not effectively solved, is the simultaneous management of the many interlocking illnesses we call co-morbidities. These involve numerous health care specialists and specialties, often in multiple separate health care systems, insurance programs, and states. The simplistic idea of a “medical home” cannot be legislated or mandated by regulation. Whether or not a single patient care relationship between healthcare professional and patient can remain at the center of modern health care is a very real question right now. The answer is “to be determined.”  If such a central relationship is replaced, we have to imagine what the world of health care will look like for us (as we ourselves and our families are patients) as well as what it will look like for those we serve on a daily basis.

11. The answer may be in front of us as we look at what health care is like for the many people who lack a primary care physician and get their care at urgent care facilities, from ad hoc specialists, emergency care centers, or forgo care in many instances. Is this a scenario we want to embrace? The choice will not be ours to make, as economic, social, and legislative forces are moving things in that direction. Primary care physicians are becoming harder to find, we know this acutely here at UM, even as new health care legislation forces the centrality of the primary care physician in the evolving superstructures of health care like the accountable care organization. The idea of a primary care person as a gatekeeper and coordinator in our indisputable world of specialty medicine may be outdated. The Norman Rockwell ideal of the GP is a lovely sentiment, but while it represented the world of 1940 in industrialized countries, it no longer fits today where the American Board of Medical Specialties certifies around 150 areas of specific medical practice. Even with my previous involvement with the ABMS I cannot name them all, and even have to think very slowly to come up with most of the names of the 24 primary member boards.

12. Professional activities, such as operative procedures, are becoming framed by guidelines, check lists, time-outs, mandated documentation, and other constraints. These formalities relegate those human performances to isolated “procedures” that neglect the totality of the patient and family.  I can’t really argue against guidelines, checklists, and documentation per se, but I believe that rigid incorporation of these things into “systems” should not replace the professionalism that must underlie the best surgical arenas. In the United Kingdom, these operative performances are described as occurring in the “surgical theatre.” The terminology is apt; great performances do not lend themselves to commoditization. Some readers might challenge these thoughts as quixotic, but I hope they are not. Humans are hard-wired to value excellence, and professionalism has passed the test of Darwinian endurance for at least two and a half millennia as evidenced in the Hippocratic Oath. The doctor –patient relationship underpins the health care that people value most, whether in our Taubman Urology Ambulatory Care Unit or in the landscapes of Africa where Doctors Without Borders tend the marginalized citizens of the world trying to survive wars, genocide, hunger, displacement, and natural disasters. We are not finished with wars and natural disasters, but should be smart enough to avoid them, minimize them, and contend with them better than we have up to now. WWI on a global scale was the result of political stupidity and human arrogance, the Halifax Disaster was a blunder of multiple human errors within the war, but the response to it revealed some of our best human virtues and behaviors.

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

David Bloom

15.     During the Art Fair I walked around for a bit with Tom Kolon and Wayland Hsaio. It was hot so I bought us some iced tea and Arnold Palmers from a stand in front of the Michigan League Building (itself a building of great art). I paid for the beverages with my favorite paper currency – two dollar bills, nice pieces of portable art and history. The front part (obverse) has a portrait of Thomas Jefferson. The backside (reverse) has an engraving of a modified version of the Trumbull painting.

16.     The engraving differs from the Trumbull original in expected and unexpected ways. As you might expect, the original was “cropped” to best fit the format of the two-dollar bill so the four farthest figures on the left and the two on the right were omitted (Left: George Wythe, William Whipple, Josiah Bartlett, and Thomas Lynch; Right: Thomas McKean and Philip Livingston). Oddly, for no good reason, the engraver also omitted George Walton, seated in the back well to the left of midline and marked by my notation as “missing.” Even more strangely, the engravers added two individuals who remain unidentified, they are indicated by my question marks. They look curiously like Waldo.

17.     Returning to urology, let me take you further back in time 2500 years ago to the Hippocratic Oath in which the author made a singular exclusion of one specific type of medical practice to be left to “specialists.” This was the matter of cutting for bladder stone, something that was to be deferred to ”specialists in that art.”  In that sense, lithotomists (urologists, today) were a unique type of practitioner with extraordinary skills. Throughout history they have been the Waldos of the medical professions, numerically uncommon and mostly hard to spot, leaving precious little of a paper trail. Urologists today are still not even one percent of the health care work force, but are still essential and hopefully easier to find.  These are the practitioners we train at Michigan Urology where the old Hippocratic idea that our work is an art has validity to me. As I said in my introduction to Rich Prager at the Chang Lecture – art can inspire us and great art usually does. When a task – any art, any performance – is accomplished with extraordinary skill, beauty, & grace we take special notice sometimes to the point of exhilaration and inspiration. In urology that art may be found in diagnostic acumen, surgical dexterity, or in acts of kindness. Art must remain an essential part of our work.

18.     So in my view no boundary exists between art and medicine. The two are as connected as you chose to believe and they are both essential to our aspirations of life, liberty, and the pursuit of happiness (if I can draw upon that great sentence once more). As this new academic season of 2014 gets underway, we will continue to practice urology, teach urology, and study urology with as much art and expertise as we can muster one patient at a time, one resident at a time, and one question at a time. We will find some moments of exhilaration and inspiration, as we navigate uncertain terrain hampered by bad legislation, industrial profiteering, relentless economic pressure, and suboptimal leadership, mine included. Still, we intend to be successful in all three missions and expect next year to produce an 8^th Chang Lecture and an 18^th season of Duckett-Lapides-Art Fair Professorships, each as worthy as we experienced last month here in Ann Arbor.

19.     Two substantial administrative appointments involve our faculty. Cheryl Lee will serve in the Dean’s Office as Director for Continuous Professional Development starting September 1. Alon Weizer has taken on the position of Medical Director of the Cancer Center Ambulatory Care Unit (CCACU) effective June 17.

20.    Yesterday one of our joint faculty members Maha Hussain, Professor of Internal Medicine and Professor of Urology, was appointed as the first Cis Maisel Professor of Oncology.  Having a named professorship is a great honor and we congratulate Maha on her achievement.

21.     Last month our internal weekly “What’s New” profiled Gary Faerber (Associate Chair for Research and the Edward J. McGuire Research Professor), John Wei (Director of Communications, Marketing, and Networks and Professor of Urology) and an update on the Pediatric Urology Division directed by John Park. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.

Best wishes, and thanks for spending time on “What’s New” this first August weekend of 2013.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu