Matula Thoughts July 7, 2017

DAB What’s New July 7, 2017

 

The Fourth, stories, & art

3789 words

This commentary from the University of Michigan Department of Urology is sent out on the first Friday of each month in two versions, the email What’s New publication and the web posting matulathoughts.org. Matula is an ancient term for diagnostic flasks once used to inspect urine.

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One.              

July delivers a new cadre of interns/residents to hospitals around the country in the midst of divisive national controversy over healthcare. Momentary acronyms – ACA, MACRA, MIPS, AHCA, BCRA, etc. – rivet public attention, just as the next acronyms de jour will do a few years hence. Whatever paradigms and regulations spill out of Washington, the daily clinical work of healthcare, education of our next generation, and expansion of knowledge and technology will continue. New house officers leaping out of their starting gates this month may scarcely notice the regulatory nuances and social policy debates. I hardly noticed such matters at a similar time in my life in 1971, but today the impact of healthcare legislation and regulation seems increasingly important. These matters, furthermore, are deeply linked to the principles celebrated this past week, because foremost in America’s ongoing republican experiment is belief in human rights and self-determination and these are inextricable from health.

July 4th represents a pause of personal freedom and relaxation for most Americans. In addition to the general right of freedom, personal freedom requires a shared sense of social justice built on laws specific to given nations, societies and localities, such as speed limits in school zones, zoning rules, or sales taxes, yet aligned with universal human rights. Not all local laws meet the bar of social justice, examples are voting restrictions, sedition or blasphemy laws, childhood marriage, and eugenic sterilization. A book on the document that made the Fourth of July possible, Our Declaration written in 2014 by Danielle Allen, dissected The Declaration of Independence word-by-word, examined the milieu in which it was constructed, and distilled the underlying principles in its second paragraph (“We hold these truths to be self-evident …”) down to three “truths” after accounting for punctuation and syntax:

  • all people are equal in being endowed with the rights of life, liberty, and the pursuit of happiness, among others;
  • humans build governments to secure these rights and political legitimacy rests upon the consent of the governed;
  • when governments fail to protect these rights, people have a right to revolt. [Our Declaration. Liveright Publishing Corp. NY. 2014. 153.]

Fireworks2

[Fireworks, Barton Hills 2017]

 

Two.

The Declaration, read from a strict originalist or textualist perspective, or even interpreted from a common-sense viewpoint, places healthcare soundly within all three of those “inalienable rights.” Life speaks for itself, from birth through childhood and adulthood navigating the hazards of trauma, disease, and disability. Liberty is the matter of self-determination, a basic tenant of our nation and democracy. This is the freedom to make judgments, speak freely, pursue education, choose careers, or adopt life styles. Liberty requires personal independence and mobility, assets that logically depend upon health. The writers of The Declaration were specific in selecting pursuit of happiness as an inalienable right. The word, happiness, appears twice in the second paragraph of The Declaration. Happiness may have had a subtly different meaning 241 years ago, but it is likely that the Committee of Five charged by Congress to write The Declaration (Thomas Jefferson, John Adams, Ben Franklin, Roger Sherman, and Robert Livingston) did not intend a trivial or hedonistic sense. They recognized that people, individually and equally, shared the right to pursue happiness as they themselves determined that happiness and government was intended to be in service to its people: “…Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness.”

The Lancet last month included a relevant statement from a World Health Organization Working Group, speaking for health and human rights of women, children, and adolescents, but applying equally to all human beings and expressing the principles of The Declaration. The particular vulnerability of women, children, and adolescents throughout most of the world is a tragic reality built on countless stories, known and unknown. The Working Group comment extends beyond its particular portfolio because all human beings are vulnerable to catastrophes of climate, geology, famine, war, oppression, violence, economics, and biology.

“The powerful interplay between health and the human rights of women, children, and adolescents forms the cornerstone of the global development agenda. When their right to health is upheld, their access to all other human rights is enhanced. The corollary holds true. When their right to health is denied, the impacts inhibit their exercise of other human rights, undermining their potential …” [Halonen T, Jilani H, Gilmore K, Bustreo F. The Lancet. 389:2087-2089, 2017]

 

Three.

House officers and fellows explain their attraction to medical careers, at least in part, by belief in social justice and the opportunity to help people. Medical school debt, duty hours, documentation-compliance, RVUs, and personal well-being dampen those original attractors. Acrimonious debates on healthcare legislation center around views of healthcare as a right as opposed to healthcare as a commodity and personal responsibility. The words right and responsibility require deeper consideration, for example in a recent radio interview Tom DeLay, former U.S. Representative from Texas (1979-1983, 1985-2006) and House Majority Leader (2003-2005) stated he doesn’t believe that health is a right, but rather a responsibility. [Interview on NPR with Jeanine Herbst March 22, 2017.] His point that government has no “constitutional role in health insurance” is accurate from a textual Constitutional perspective, however to reduce the generality of healthcare to the particularity of health care insurance is neither logical nor helpful in the national debate. I use the DeLay quote only to introduce the consideration of healthcare as a right, not because of any claim to healthcare expertise or salutary wisdom regarding social justice he might offer.

Ian & Ted

[House officers Matt Lee & Ian McLaren choosing freedom over local rules.]

The truth in healthcare is close to home for most people. Health care involves each of us from antenatal days to final days of life. It is not productive to frame the national healthcare debate in the context of healthcare insurance, as insurance is only one method to fund a nation’s healthcare needs. Viewing the enormous panorama of national healthcare from only the insurance perspective makes no more sense than expecting the motor vehicle insurance sector to cover all motor vehicle costs including purchase, gasoline, cleaning, maintenance, safety inspections, collision repair, and damage from acts of nature, as well as highway safety, research and development, petrochemical sourcing, and traffic control.

The insurance industry, arguably, began at Lloyds Coffee House in 1686 of London as a source of shipping news and later marine insurance to mitigate catastrophic risks of sea commerce (above c. 1800 unknown cartoonist. Wikipedia). Insurance did not cover all expenses of sea trade, it covered true catastrophe, not operating costs, torn sails, or men overboard. The origin and evolution of American health insurance and the co-mingling of it with employment status is a story with many twists and turns, and federal involvement added further complexity. The result is an intertwined morass of funding streams and regulations, kinda looking like the Lloyd’s cartoon above. Rather than partisan ping pong, the solution to the national healthcare dilemma requires thoughtful bipartisan consideration of a framework to define rational public and private domains, responsibilities, and funding.

 

Four. 

Debate, essential to democracy, requires free speech and an open society that embraces education and cosmopolitanism. Conversations that challenge opinions, introduce ideas, and work toward consensus are fundamental to civic life as well as just and constructive public policies. This is how democracy works best, whether on national stages or in local workplaces.

Point counterpoint

We bring debate to Michigan Urology with point-counterpoint sessions at Grand Rounds when two residents square off with contrasting points of view to sway the rest of us. Our discussions are more prosaic than debates of health care as a right or commodity, because we are focused on learning urology. For example, Parth Shah recently offered the opinion that radical cystectomy should be performed by traditional open technique while Zach Koloff argued for the robotic platform (pictured above). They reinforced their positions with historical perspective and current data, deploying classic elements of argument. The impeccable characters of Zach and Parth represented ethos, their data supported logos of their claims, and considerations of pain, costs, complications, learning curves, and fiduciary responsibility bore pathos in the traditional rhetoric triad. The hospital conference room, newly refinished, was pretty much at capacity with about 45 in attendance including the usual 4-6 lurking at the back of the room with coffee and opportunity for stealthy egress.

 

Five.

The recurring biologic experiment of civilization evolved occasionally from the social networks animals depend upon to maintain each generation. A few eusocial species, if I may flip back to the writings of E.O. Wilson, create societies that successfully and become durable “megaspecies” in and of themselves. Wasp, bees, and ants are most notable, using chemicals or motions for communication. Specific signals trigger unified mass social actions such as directional movement, panic, or war. Ants, for example, manage their colonies with pheromones.

Fire_ants_01

[Above: marching fire ants, Stephen Ausmus http://www.ars.usda.gov/is/graphics/photos/dec04/k11622-1.htm]

The human advantage with civilizations is an ability to build and change them over centuries through communications transcending many generations and even millennia, allowing learning, creativity, and innovation. Individuals apply critical thinking, reexamine assumptions, experiment, analyze methodologically, and cooperate for durable change, passing information along to successive generations. Individuals naturally have individual points of view and debate allows cooperation and learning, leading to resolution, reconciliation, and centrism.  A strong center is essential for robust civilization, but just as ants and bees, humans are subject to mass manipulation by signals that, usually for us are money, ideology, propaganda, quackery, or charisma.

 

Six.

Conspiracy theories attract and entertain.  We are drawn to them, being hardwired to favor stories that fit our predispositions or play to our anxieties. Conspiracy ideas provide lazy mental short-circuits that displace critical thinking and rational re-examination of assumptions. Some conspiracies, of course, prove authentic, although my limited experience in the military and as an amateur student of history, is that major conspiracies are unlikely to remain long-concealed. Democracy is leaky due to First Amendment protections of free speech. Rare exceptions, such as campaigns that “loose lips sink ships” or the Manhattan Project, demonstrate that free society can maintain secrecy for critical intervals on rare occasions when the need is essential and widely understood. The rarity of these exceptions preserves their exceptionalism. When a regime tilts toward authoritarian rule and censorship becomes common, democracy slides away.

It is not wrong that news sources are polarized. The left side of the political spectrum reads left-sided sources while the right reads right-sided sources, and everyone blends opinions, facts, and stories to support their myths and to ascertain facts. The middle of the political spectrum is where democracy finds its balance, but sources of news and opinion that the center trusts are uncertain and conspiracy fears can spread like viruses.

400px-RoswellDailyRecordJuly8,1947

On this day in 1947 Major Jesse Marcel, intelligence officer of the 509th Bomber Group at Roswell Army Air Field inspected a debris field where an incident was claimed to have happened. [Above: Roswell Daily Record, July 8, 1947] Stories still emanate from that incident, blending facts and myths with no commonly-held authoritative version, but only colorful conspiracy theories. Those of us who grew up with the original X-Files series (1993-2002), centered around Roswell-type mysteries, are familiar with the haunting tune and the invitation to further inquiry: “the truth is out there.” The quest for truth is humanity’s big challenge.

All living creatures discern information from ambient noise. We humans create stories out of information and from the stories invent myths, models, and theories to derive meaning and utility. Careful analysis, by verification or scientific testing, pulls truth from facts, myths, models, and theories, nonetheless, truth remains elusive. The intersection of news and entertainment risks confusion and credibility as when the radio broadcast War of the Worlds in 1938 by Orson Wells created a minor panic for listeners who tuned in after its introduction as a radio play and thought that Martians were actually invading Earth. When trusted news anchors portray their roles in TV and film fiction they diminish their credibility. Worse, deliberate fake news tilts political opinion and instigates conspiracy fears that cannibalize civilized society by devouring trust that is the currency of civilized people.

 

Seven.          

Lapides copy 3

True facts. The story of Jack Lapides, former chief of urology here at Michigan, educator, and innovator (above) was briefly told in an obituary column his sister requested after he passed away. [New York Times. Nov 19, 1995] (The published version has a single typo, introduced by the newspaper that must have thought the reference to Charles Huggins was “Charles Higgins.”)  Jack’s surgical accomplishments continue to show up in urology clinics around the world, illustrating the long reach of an innovative surgeon. Surgeons fix problems, and one of Jack’s surgical innovations was the vesicostomy, a solution for bladder and sphincteric dysfunction by making an opening on the abdominal wall.

The concept and practice of urinary diversion preceded Lapides by many decades with the standard of care for neuropathic bladder in the mid-20th century consisting of suprapubic cystotomy, ureterosigmoidostomy, ureteroileostomy, cutaneous ureterostomy or nephrostomy. Lapides favored vesicostomy to eliminate urinary stasis, high pressures, and urethral incontinence, but standard ostomy devices were unreliable: “Initially, we employed the usual types of fecal colostomy devices for collecting the urine, but soon became disenchanted with the various appliances because of bulkiness, leaking of urine, skin reaction, malodor, and difficulty in changing the apparatus.”  [Lapides J, Boyd R, Fellman SL.  A urinary ileostomy device.  J Urol. 1958. 79:353-355.] Lapides created a device utilizing a rubber ring with changeable collecting condoms, being rapidly replaceable, streamlined and more acceptable to patients. As it gained popularity it came to be known as the Lapides urinary ileostomy. [Lapides J, Ajemian EP, Lichtwardt JR. Cutaneous vesicostomy. J.Urol. 1960. 84:609-14.]

Pediatric urologists utilize vesicostomy occasionally. Keith Schneider, pediatric surgeon in New York, and John Duckett, pediatric urologist in Philadelphia, subsequently described vesicostomy techniques of their own, but these were mostly replaced by Lapides’s clean intermittent catheterization methods after 1971 and the reconstruction approaches of W. Hardy Hendren. We honor the Duckett and Lapides names with lectureships here in Ann Arbor in July, as the first academic events of the residency training season. I carry the Lapides name with my endowed professorship and Hardy (mentor to John Park) continues to be an inspiration and friend to many of us in Ann Arbor.

 

Eight.

Intersecting story. Last year our departmental office got a call from Peggy Hawkins of Chevy Chase, Maryland, who identified herself as the sister of a former Lapides patient in need of help. Her brother, we can call Larry, was living in Florida and dependent on a vesicostomy Lapides created in June, 1968, but Larry was having trouble obtaining stomal supplies. Peggy, recalling the name Lapides, contacted our office for help. I called Larry and we got him in touch with our UM stomal experts who found some solutions.

Peggy called back recently to tell me that Larry recently passed away and filled me in on Larry’s amazing story. She assures me that Larry would have been pleased to share the following details of his life, particularly the importance of his vesicostomy to him.

Born in 1943, Larry was the only son in a family with two sisters. Popular and athletic, he played football and ran track in high school. After graduation from college with a major in political science he joined the United States Army as a Second Lieutenant and married his girl-friend. Larry was sent to Vietnam with the 173rd Airborne Brigade in 1967. The Tét Offensive changed his life. Launched on January 30, 1968 by 80,000 North Vietnamese and Viet Cong forces during the Tét lunar new year holiday, the offensive was a coordinated series of attacks on over 100 cities and towns in South Vietnam. A mortar round that first day exploded just behind Larry causing tremendous concussive injury to his back and spinal cord with extensive shrapnel injuries, particularly to lung, liver, and upper extremities. The triage officer didn’t expect him to live, but Larry defied expectations and survived first to the field hospital, then to a general hospital in Japan, and next to Valley Forge Army Hospital in Pennsylvania, but with paraplegia and consequent lower urinary tract dysfunction that translated to sepsis and upper tract deterioration.

Bronze star

His medical condition continued to decline at Valley Forge and around this time a son was born. Larry separated from the Army in June, 1968 and was sent to the Ann Arbor VA that month where he came under the care of Jack Lapides who understood the deleterious nature of high pressures in the neurogenic bladder who explained that vesicostomy might extend Larry’s life another ten years, Peggy recalled. The procedure that June turned around Larry’s deteriorating clinical course and provided him another 48 years of independent life without urinary tract problems as long as he had access to stomal supplies.

After recovering from the operation and stabilization of his health Larry enrolled in law school in the fall of 1969, living in a nearby apartment with reasonable wheelchair access. With his Juris Doctorate he moved to Florida in 1972 mainly because of the flat terrain and more favorable climate, finding work in politics early on as an advocate for Veterans in Tallahassee. Larry received a Purple Heart and Bronze Star (above) with a “V” Device (for valor) in 1974. In 1978 he ran for public office and served 4 terms (1978-1986) in the Florida House of Representatives where he chaired the Veterans Affairs Committee and impacted a groundbreaking generic drug law. He was elected Dade County Commissioner 1988-1994 and sponsored nation’s first family leave ordinance (Miami-Dade employees 1992), helped the Miami community recover after Hurricane Andrew and found creative solutions to the influx of Haitian immigrants in Jackson Memorial Hospital and Dade County Public Schools. Larry served on the Board of Vietnam Veterans of America. His network of political friends included Bill Clinton and Senator Tom Harkin, who introduced the Americans with Disabilities Act in the Senate. Larry’s son died at age 34 in 2002, leaving Larry 2 grandchildren – a granddaughter who teaches kindergarten and a grandson currently serving in the Army. His step-son works for the U.S. Secret Service.

During his 48 years with a stoma Larry was able to engage socially and professionally. Never in those 48 years did he have a UTI, upper tract problems, or stomal problems, although access to stomal appliances, necessary for daily peace of mind, became increasingly difficult as the market for them disappeared. Larry died recently from multisystem problems, but without urinary tract issues. He will be buried at Arlington National Cemetery.

 

Nine.

The Tét Offensive of 1968 continued through February. Although a military defeat for the North it intensified the American public opposition to the war and created a crisis in the Johnson administration. The “credibility gap” that had become apparent in 1967 widened in 1968, the year US casualties peaked with 16,592 soldiers killed. In February that year the US Selective service called for a draft of 48,000 men and on February 28 Secretary of Defense Robert McNamara stepped down from office. McNamara had been a long-time college friend of my UCLA urology professor Willard Goodwin and coincidentally lived in Ann Arbor for a short period as president of Ford Motor Company. As early as mid-1966 McNamara, as defense secretary believed that “there was no reasonable way to bring the war to an end soon” and that we should quickly find a political solution with North Vietnam and the Viet Cong. These were marginal opinions in the Johnson administration. [McNamara. In Retrospect. 1995. P 262] Many conspiracy theories abounded about the Vietnam War and some still resonate, but McNamara’s book lays out the story clearly, explaining the mistakes of management, failures of duty, and sins of pride led to escalation of conflict and flew out of control. The Fog of War. Lessons from the Life of Robert S. McNamara, a film by Errol Morris and a book by James Blight and Janet Lang, explains the cautionary tale.

 

Ten.

Chang Lecture.  Medicine without art is a commodity. Not to disparage commodities, we expect them to be dependable, available, and standard in quality. With health care however we prize human values of excellence, kindness, discernment, attention, discovery, innovation, and even virtuosity. For all of us as patients and families, our healthcare needs and expectations go beyond mere provision of commodities. Many services in medicine can be managed as commodities: blood pressure screenings, flu shots, blood draws, and dental hygiene are typical examples, although even these can be done artfully or not.  The routine blood pressure check requires thoughtful matching of cuff to body size and a few minutes of relaxation that puts the recipient at ease. Any human performance can be given with care, enthusiasm, and art – or not.

My aunt Evelyn Brodzinski, an artist, once said “Art is anything that is choice” after I asked her “What is art?” I quote her definition often. Art consists of the choices we make in the performances we give, whether delivery of a job, doodling on paper, whistling a tune, writing an essay, taking a picture, drawing a blood sample, or doing a surgical procedure. Any vocation can and should be performed artfully. Universities have a duty to propel this aspiration in all their fields of study, and the artful provision of healthcare should be at the top of any list of fields. The study of art is the study of choices in the world.

Gibbes

[Above: Lawrence exhibit Gibbs Museum, Charleston, SC]

We began the Chang Lecture on Art and Medicine in recognition of this obligation of our university. Such a lecture could just as easily come out of any of the 30 departments in our Medical School.  It could also have come from Michigan’s Department of Art History or School of Social Work. We brought it forward from the Department of Urology inspired by the linkage of art and medicine in the family of Dr. Cheng-Yang Chang, a urologist who trained and practiced at the University of Michigan, as well as founded a medical school in Taiwan and later practiced in Flint.  His father, Ku-Nien Chang was a famous painter in China and Dr. Chang’s oldest son is a urologist in Albany NY, trained here in Ann Arbor under Ed McGuire. Dr. Chang’s youngest son is a financial analyst in Chicago and one of UM’s best alumni supporters. This year Dr. David Watts, a prominent gastroenterologist in San Francisco and nationally-known humanist, will give the Chang Lecture July 20, 5 PM, Ford Auditorium.

AAAF 2016

[Life and the pursuit of happiness on Liberty. Art Fair. 2016]

 

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

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

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

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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

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


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


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

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

April facts

DAB Matula Thoughts April 7, 2017

 

April facts – mischievous & urological

3687 words

 

One.              

            April, the first 30-day month of the year, opens up the northern hemisphere spring with welcome visibility of diverse flora and fauna. It should surprise no one that the diversity of life sustains all life on the planet and loss of that diversity imperils everything. A multitude of critters share our space and today it is the wombat that comes to my mind. Australian newspapers The Sydney Herald and The Age reported a wombat attack this day in 2010 when a man named Bruce Kringle ended up in the hospital after mauling by the marsupial. The worldwide British Broadcasting Corporation quickly picked up the news. These sizable animals average over 3 feet and 60 pounds as adults. [Photo by JJ Johnson. 29 November 2009. Taken at Maria Island National Park, Tasmania.] Territorial infringement was likely in play in this instance, as the victim was living in a camper when he stepped out the door and encountered the angry wombat, unusual behavior for the animal and ultimately self-destructive after Kringle found an ax and made short work of it on this summertime February day in Australia.

The Wombat coincidence this day on this April day piqued my interest, because in a previous April, 1998, the British Journal of Urology (BJU) published an article on wombat uroflowmetry. [D. Johnson. Case report. Observations on the uninhibited bladder of the common wombat. BJUI. 81:641-642, 1998.] For those readers uninitiated regarding matters of scientific micturition, uroflowmetry is the measurement of the flow rate of urine during the process of emptying the bladder. Mankind is naturally curious about its personal byproducts and inspection of sputum, urine, feces, etc. has offered clues to understanding disease since the times of the earliest healers. Of course most mammals have olfactory interest in their own urine and that of others, as evidenced in the canine world. Uroflowmetry provides true facts about urination, thanks to our ability to measure time and volume, as well as understand velocity.

My interest in uroflowmetry preceded the wombat stories and goes back to Walter Reed Army Medical Center where my chief, Ray Stutzman, introduced me to the concept of timed uroflowmetry and we wrote a paper comparing it to instrumental uroflowmetry. [J. Urol. 133:421, 1985] I then wondered about uroflowmetry in other species and the elephant seemed a good place to start. Discussion with the elephant-keeper at the Washington National Zoo taught me something about pachyderm urologic habits, but we never completed the project, mainly because of a difference of opinion on the distribution of the tasks required by the methodology. Timed uroflowmetry requires a collection device and a stopwatch to measure the volume during 5 seconds of mid-flow. All of the elephants at the Washington Zoo at the time were female and their streams therefore required a collection device both large in volume and wide in aperture– basically a big bucket. The unpredictability of elephant micturition required someone standing in place with the bucket. Since the uroflowmetry idea was mine and the elephant-keeper was on better terms with the pachyderm than I was, it seemed reasonable for me to hold the watch while the other guy held the bucket. The elephant-keeper disagreed with that assignment and claimed the stopwatch. Given that stalemate, the study has yet to be performed and awaits an ambitious medical student or resident, or a more flexible elephant trainer.

Another elephant crossed my path around this time of year after Ed McGuire brought me to Michigan. A child with gross hematuria presented to clinic with her grandparents and we diagnosed urologic malignancy. After surgery she remained in hospital for further treatment and by this point the parents had come to town. They were circus people and owned a number of animals including a young female elephant. Domino’s Farms graciously allowed the family to camp out on their property for the weeks of therapy, and one spring afternoon the child’s family invited our pediatric urology team and kids for elephant rides.

 

Two.            

            Planarial detour. Scientists crave facts and know their job is to ferret out true facts. Bill McRoberts, colleague in Kentucky, friend, and our third Duckett Lecturer at Michigan used to tell his residents “a little fact trumps a lot of myth,” an idea parallel to Coffey’s advice to trainees:  “you have to understand the difference between facts and true facts.” Evidence, analysis, and experiment are the ways we come to verifiable truths and enduring realities that constitute true facts. While all biological creatures deal with facts of their environment, many facts are only transient realities. A planarium, for example, may sense that its world is 20°C and that food is available straight ahead of its momentary motion, but those facts may change quickly. We humans can examine myths, discover momentary facts, create hypotheses, and perform experiments in search of something we call the truth, an aspiration we think is unique to our species.

Planaria, by the way, are among the simplest animals to manage their waste with a dedicated excretory system.  Paired flame and tube cells ending in a pore assemble as protonephridial tubules along the length of the flatworm. These are capable of regeneration. [JC Rink, HT-K Vu, AS Alvarado. The maintenance and regeneration of the planarian excretory system are regulated by EGFR signaling. Development. 138:3769, 2011] Planarial flow rates could be a topic for a future study. More practically, the mechanism of planarian excretory regeneration could be turned to human renal replacement therapy, thus proving the point that today’s obscure fact may be tomorrow’s revolutionary insight.

[Above: planarian Dugesia subtentaculata. From Santa Fe, Montseny, Catalonia. Wikimedia Commons. Eduard Solà.]

[Above and below: reproductive and excretory systems of flatworm. Source – Wikimedia Commons, Putaringonit.]

            When the wombat uroflowmetry paper in the BJU caught my attention in 1998, I suspected a prank, something not unknown in British medical publications, particularly around the month of April. Thinking a clever reply might be appreciated by the journal, I resorted to limerick form in a letter to the editor, Jeff Chisholm. Surprisingly, my letter was published and now constitutes the only “poetry” of any sort to find its way into my CV. [DA Bloom. Re: Wombat uroflowmetry. BJU 83:365, 1999.] Chisholm annotated my reply: “Edited versions – apologies to the author!” The annotation was in this limerick:

“Lo, the wombat – it all must be true

So free when it’s not in the zoo

Pees lots when it poops

By well-used neural loops

As told in the new BJU”

 

Three.

          Pranks, myths, and propaganda veer from the true facts attended to so carefully in our professions. Last spring, sitting in on the class my daughter Emily, assistant professor in English, was teaching at Columbia University I heard her challenge a familiar myth with data from a paper in Science. [Mehl. Science. 317 (5834): 82, 2007.] The myth was that women spoke more than men, and observation of my children and grandchildren still supports that idea. The thing about myths, however, is that they usually short-circuit our best efforts to think critically. Appealing to the lazy tendencies of our brains, they get an easy pass for “truth.” Although I subscribe to Science, I had missed that particular article (and likely hundreds of other important ones since then). Matthias Mehl, associate professor of psychology and author of the paper, studied 210 women and 186 men with a voice-activated device that captured 30 seconds of conversation every 12.5 minutes (5% of the day) and found that women used 16,215 words and men 15,669 words daily – no significant difference. One might argue that possibly women used longer words for more complex conversations, and inspire another study. Another question, also heavily dependent on educational, socio-economic, and occupational levels of  subjects tested would be how many words does “an average person” hear every day? It is likely that fewer words are actually comprehended than spoken.

Word count interests me in relation to this monthly column, What’s New/Matula Thoughts. Approaching 4000 words it offers a substantial amount to read, a quarter of what most people speak every day. It is surely vain on my part to think that the general readership consumes all these words critically, although a few friends read this more carefully than I write it. My point in writing, however, is that it fills some fundamental personal need to communicate beyond the simple necessities of survival and daily work, the need that our distant ancestors (Homo sapiens, Neanderthals, and their hybrids) fulfilled some 30,000 years ago on the walls of their cave dwellings. These particular electronic postings you now read are hardly so novel, artistic, or durable.

 

Four.             

            More on words. Considering a career in urology a medical student at Pritzker Medical School in Chicago, Logan Galansky, recently contacted me for advice and as she explained her previous work in hearing and learning she described the 30 million words idea – the hypothesis that children who heard that many words by age 3 years had a lifetime advantage over those who were exposed to much less. [B Hart & T Risley. (2003). The early catastrophe: The 30 million word gap by age 3. American Educator, 27(1): 4 – 9.] Complicating any easy assumptions, however, is the fact that the study compared children from “professional families” to children from “impoverished families” in Kansas City, KS in the 1960’s where other confounders beyond experiential words were at play. The pivotal study involved  42 families that were divided into 4 socioeconomic groups. Although scrutiny detracts from the easy conclusion it certainly is plausible, if not likely, that richer vocabulary experiences build more robust vocabulary inventories, and those inventories are an advantage in life.

Our Department of Urology Faculty Retreat next week is a sort of spring training for the next decade of urology at the University of Michigan. Each clinical division and key domain, such as education or the Dow Health Research Division, will present strategic visions. Individual faculty have updated their web profiles and we should get a pretty good sense of ourselves as an organization today and what we hope for in the intermediate future. How many words will be spoken at this retreat? Given pauses, breaks, and other interruptions, and assuming a leisurely rate of 100 words per minute (130-150 wpm may be more typical of conversational speech) over 5 hours we may hear 30,000 words. Who knows what will stick or what people will take away, but I hope we will align around our mission and that we will understand our divisional strategies and visions of the future.

 

Five.              

            Disparities. Important lessons from Star Wars, observed by The Economist and mentioned here last month, bear repetition. First, economic disparities are inevitable in the galaxy, in spite of advancing technology. Second, although free trade advances economic growth, free trade will never benefit everyone equally; some “humans will still labor at dangerous and unpleasant tasks” because of inequities within political systems.

Society benefits substantially by mitigating disparities that, while inevitable in humanity, impede the common good. Society gains when its entire human capital is educated, productive, healthy, and kind. If only certain privileged subsets of its potential workforce have opportunity for education, employment, and productivity, then the potential of that society is diminished. A generation ago, scientific investigation of healthcare disparities was not high on the ladder of interest in academia, federal funding, or industry. This has changed greatly, and our Urology Department Dow Health Services Research Division reflects the new attention. An important paper in JAMA earlier this year looked at trends and patterns of disparities in cancer mortality by counties in the USA from 1980-2014 and the results relevant to urology are riveting. [AH Mokdad et al, corresponding author CJL Murray JAMA. 317:388-406; 2017.]

Prostate cancer:

Kidney cancer:

Testicular cancer:

The United States is a large and diverse country, but why people with specific diseases should have different regional disease frequencies, expectations of care, and survival is a complex question with many answers. Regional variations of disease frequency and survival can depend upon environmental factors such as air or water safety, occupational hazards, poverty, food safety, public safety, weather conditions, and many other factors that vary according to geography and socio-economic conditions. Looking at the maps we have to agree with Dorothy, in The Wizard of Oz, that the center of the country is a good place to call home.

 

Six.

           Centrism. A cornerstone aspiration of American representational democracy is justice, opportunity, and dignity for all participants. This must be balanced against the centrist tendency inherent in majority rule of the electorate. Cosmopolitanism must be respected and those who are disadvantaged require a humane safety net. Life, liberty, and the pursuit of happiness are those basic Jeffersonian beliefs articulated in the Declaration of Independence, but even after more than 200 years they remain work-in-progress, complicated by a world that is rapidly changing in terms of socio-economic, geo-political, environmental, demographic, and technology factors.

The political center of the United States will always be a matter of debate, however the geographic center of the contiguous United States according to the US National Geodetic Survey is 39°50′N 98°35′W. This spot happens to be in Kansas, approximately 12 miles south of the mid KansasNebraska border and 2.6 miles northwest of the center of the city of Lebanon.  Not too far south and east of that point is Abilene, Kansas where Dwight David Eisenhower was raised.

Health care is unquestionably wrapped up in the idea of life, liberty, and the pursuit of happiness, and healthcare politics concerned most presidents even before the mid-20th century. Around that point in time the AMA position was that the federal government should not be involved in healthcare, while Truman favored national health insurance and Eisenhower sought legislation to support the healthcare insurance industry.

On April 16, 1953, twelve weeks into his presidency Eisenhower delivered one of his greatest speeches. This was just a month and a half after the death of Stalin and, as the president then knew, the first hydrogen bomb would be tested within a year (code-named Castle Bravo it was detonated March 1, 1954 at Bikini Atoll, Marshall Islands). Eisenhower saw an opportunity to reset the increasingly costly escalation of the cold war. The occasion was a meeting of the American Society of Newspaper Editors in Washington, DC. Eisenhower worried about the disparity between military spending and the spending of a nation on the life, liberty, and pursuit of happiness of its people.

“In this spring of 1953 the free world weighs one question above all others: the chances for a just peace for all peoples… “

No one dared remind Eisenhower that liberty required a robust and costly position of defense, but he was convinced that the escalating costs were not only excessive, but also realistically unnecessary. He believed that the nations of the world had reached a point where the worst that could be expected by the escalation was terminal nuclear war while the best hope was

“… a life of perpetual fear and tension; a burden of arms draining the wealth and labor of all peoples; a wasting of strength that defies the American system or the Soviet system or any system to achieve true abundance and happiness for all the peoples of this earth. Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed those who are cold and not clothed. The world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children.”

He noted that the cost of one heavy bomber equated to modern brick schools in more than 30 cities, a single destroyer equalled a new home for 8,000 people, or a fighter plane cost a half million bushels of wheat. Inflation and technology have pushed the costs much higher.

 

Seven.

            The Nesbit Society and the AUA come to mind as spring approaches. The AUA originated in 1902 in New York City when urologist Ramon Guiteras felt the need to congregate with other urologists. Barely 17 years later his colleague Hugh Cabot in Boston, returning from WWI, began preparations to move to Ann Arbor attracted by the opportunity to organize a medical school and hospital system to suit the changing times of health care. Cabot’s successor, Reed Nesbit, became the first head of urology at Michigan, presiding for nearly 40 years, followed by Jack Lapides. The Nesbit Society was formed in 1972 under the leadership of the Nesbit/Lapides trainee John Konnak, who by then had become a faculty member. The legacy of these great teachers and urologists is the Nesbit Society, now with 324 members. To a large extent, it is the Nesbit Society to whom this monthly electronic posting is directed (although a few members prefer a hard copy and Sandra Heskett graciously obliges). It is always a delight for me to hear from our Nesbit alumni and friends. John Hall (Nesbit 1970), for example, sent me this phrase that has informed his practice throughout his excellent career in Traverse City:  “We don’t practice medicine until we get it right, we keep on practicing until we will never get it wrong.” Hall’s Theory of Medical Education, like the Hippocratic aphorisms, distills wisdom into a phrase that you can carry around and re-inspire yourself when the going gets rough on a given day in clinic or operating room. This is one of the ways good professionals inoculate themselves against burn-out.

The Nesbit Society meets twice a year: once during the AUA national meeting in Boston this year on Sunday May 14 and all Nesbit members and friends of the department are welcome. The second occasion is our alumni weekend here in Ann Arbor September 14-16.

 

 

Eight.                        

           Most species congregate and the chairs of our academic departments do this with some regularity. I came across this picture of such a congregation 3 years ago in April when Mike Johns was interim EVPMA. This particular dinner was at The Earl, and the picture was taken before everyone had arrived, but it turned out to be my best picture of the evening. [From left: Karin Muraszko, Valerie Opipari, John Voorhees, Mike Johns, Carol Bradford, Reed Dunnick.]

The clinical departments are where the rubber meets the road in carrying out the missions of our UM Health System mission. Departments have been the building blocks of universities for hundreds of years, and academic medicine departments have effectively educated their successors, expanded the conceptual basis of their fields, and performed the essential transactions of clinical care over the past century. The clinical mission is the milieu for education and research as well as the financial engine for academic medicine. The changing economic, regulatory, and technological environments threaten the delicate balance of that mission. At Michigan our ambulatory care unit (ACU) model of delivering care has been successful, with the healthcare providers in central roles of making local operational general strategic decisions more effectively than management by managerial accounting methodology. This is largely the concept of lean process management. Clinical departments bring a third dimension of the academic mission to ambulatory clinics of providers and patients.

 

Nine.

          April, the cruelest month in the view of TS Eliot, can be mischievous and its first day, April Fool’s, sets the tone. The origin of April Fools Day, may well have to do with April being the first calendar month of the year in medieval European towns when March 25 marked New Year’s Day. April in Ann Arbor often brings mischief since a given day may be spring-like while the next might be wintry. That shouldn’t be surprising, as nature routinely throws curve balls to test our fitness. Actually, yesterday afternoon I saw snow flurries from my office window and more snow last blustery evening.

[Above: April 2, 2016 at home. Below: April 13, 2016 Old Mott on left, Main Hospital center, and Taubman on left.]

 

 

Ten.

              Biology’s astonishing diversity sustains our particular human biologic niche, yet ironically our very presence as a species chips away at biologic diversity and erodes our niche. This erosion has been going on for a long time and the angry wombat is only one tiny example. Its likely ancestor, the Diprotodon (meaning two forward teeth), was the largest known marsupial and a member of the Australian megafauna that existed from 1.6 million years ago until extinction around 46,000 years ago. That latter date coincides with the time our human ancestors were making their first cave dwelling paintings as they were eating the megafauna. Koalas and wombats are, perhaps, miniaturized surviving versions of the rhinoceros-sized Diprotodon. The wombat’s dental plan facilitates its Darwinian niche, allowing it to tunnel forward vigorously. Cleverly, its marsupial pouch opens retrograde, to avoid collecting dirt as it burrows. After 3-week gestations, the young live in the pouches for 6-7 months, but still do not wean until 15 months of age. Wombats have no tails and their tough rear hide is cartilaginous most posteriorly, making it resistant to predators. Wombat scat (below) is oddly a nearly perfect cubic form, somehow resulting from its peculiar physiology. Wombat groups are variously called wisdoms, mobs, or colonies. [Wikipedia facts, Photo JJ Harrison]

As the environment changes, you never quite know what to expect each day going forward. One value of knowing some history is that it gives you a little confidence of what to expect. For example, if you know the earthquake history of your location has a frequency of once in a millennium, with the last recorded 100 years ago, you might reasonably conclude that it is safe to live there. More immediately, if the sidewalk you are about to traverse is riddled with pigeon droppings, you might cross the street to walk on more auspicious pavement. When Bruce Kringle woke up 7 years ago in Australia, he certainly had no idea that an angry wombat was going to take him on when he stepped out of his mobile home, although had he examined the ground he might have recognized its unique cubic scat.

[Wikimedia Commons: Bjørn Christian Tørrissen. http://bjornfree.com/galleries.html.]

 

Postscript.   John Barry, in response to the picture of the Olds 88 last month wrote: “Looks like a 1951 Oldsmobile 88 K-body 2 door sedan with a V-8 engine and a Hydramatic transmission. I had one when I was a senior in high school. Great car. I used to buy cars, fix them up and resell them from my parent’s driveway.

Thank you for reading Matula Thoughts this April, 2017.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

March Thoughts

DAB What’s New March 3, 2017

March Thoughts

3741 words

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

 

the_victors_sheet_music

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

or

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

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

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

louis_elbel

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

march

 

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

cave_painting_l

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

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

the-she-wolf

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

 

Three.

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

george_w-_johnson_1898

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

berlinerdisc1897

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

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

jackie_brenston-1

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

 

Four.

1949_oldsmobile_88

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

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

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

 

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

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

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

440px-muenchhausen_herrfurth_7_500x789

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

 

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

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

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

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

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

 

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

sterns-2012

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

 

Eight.

metro

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

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

 

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

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

 

Ten.

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

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

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

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

734-232-4943

dabloom@umich.edu

 

February, Sunday feelings, and Monday facts

DAB What’s New February 3, 2017

February lows and highs; Sunday feelings, Monday facts
3916 words

 

icicle

One.
February is the nadir of winter as well as the shortest and most variable month, with average snowfalls of 13 inches, highs of 35℉, and lows of 20℉ in Ann Arbor (U.S. Climate Data. Wikipedia). Even though not quite the coldest month February seems the wintriest, lacking the enticements of December holidays and the exhilaration of January’s new year. This February, a regular one without the extra day, allows only 20 business days to pay the challenging bills of academic urology. Educational and research expenses always exceed their funding streams and require clinical and philanthropic dollars to maintain them.

korlebu

[Michigan team and the Korle-Bu and Military Hospital staff, Accra.]

Last month 3 faculty and 2 residents escaped Michigan winter for a week of operating and teaching in Ghana. Sue and the late Carl Van Appledorn initiated this yearly trip and other generous donors help offset its draw on clinical revenue. John Park, Casey Dauw, and our former faculty member Humphrey Atiemo (now Program Director at Henry Ford Hospital) accompanied by residents Yooni Yi (UM) and Dan Pucheril (HFH) spent a productive week in Accra. Casey led the team in performing the first successful percutaneous nephrolithotomy in that part of the world. The Korle-Bu Hospital, affiliated with the University of Ghana, is one of the largest teaching hospitals in Africa. John Park will give further details in an upcoming What’s New/Matula Thoughts.

casey-perc

[Casey at bat.]

Back here in the USA the economic side of health care is ambiguous. Governmental funding, public policy, regulation, corporatization of the clinical domain, market segmentation, and escalating costs in pharmacologic/technology industries are some factors in the turmoil. Most healthcare industries maintain the public trust and behave admirably in seeking profits and market share – we certainly see this in the companies with whom we deal such as Johnson & Johnson, Medtronic, Boston Scientific, Storz, etc.

A few egregious actors stand out. The Mylan company’s repackaging of a natural chemical (epinephrine, for which nature holds the patent) with a syringe and needle was a mildly clever gimmick, but creating a monopoly for this lifesaving device and raising the prices for a two-pack from $100 in 2007 to $608 in 2016 is greed beyond the bounds of public acceptance. Mylan’s half price “generic,” offered recently, is a pathetic peace-offering to the public – a generic of a generic is elementary Orwellian Newspeak. [Epinephrine auto-injectors for anaphylaxis. JAMA; 317:313, 2017.] Teva Pharmaceutical was another one of the six drug makers recently sued by 20 state lawmakers on price fixing. These two companies are the largest generic drug makers by market cap. (It must have been awkward for Mylan’s CEO Heather Bresch to justify EpiPen prices because of research and development expenses in testimony to the House Oversight and Government Reform Committee last October.) [M. Krey. Investor’s Business Daily. Mylan launches cheaper EpiPen generic amid drug pricing saga. 12/16/16.] Below: Table A from 10/5/16 letter from CMS Administrator Andrew Slavitt to Senator Ron Wyden regarding Medicaid and Medicare Part D Expenditures on EpiPen products.

table-epipen

 

search
Two.

Regulation for the public good is essential in a world economy of 7 billion people and GDP of $78 trillion. All businesses exist because of the public trust, going back to the early days of the limited-liability joint-stock company, a story explained in a book called The Company that Julian Wan gave me years ago [John Micklethwait & Adrian Woolridge. Modern Library, NY 2003.] Most US businesses understand their public responsibilities, but uncommon greedy actors erode public trust and diminish the standards for the rest.

Regulation is under attack. It is inevitable that government regulations dampen corporate bottom-lines and short-term economic growth, that is the nature of regulation, but few rational people can deny that serious regulation of highway traffic, airways, nuclear energy, banks, health care, etc. is in the public interest. Offensive governmental regulatory overreach is bound to happen in any complex bureaucracy and should be called out when discovered, but these instances hardly disprove the necessity for regulation by impartial public agencies and civil servants in a healthy democratic society.

By now, in February’s wintry days of cold and snow, the EpiPen story is old news, but we hope that the protective regulatory functions of governmental regulation do not get snowed over or subsumed by corporate world grudges. Like most things in life, balance is essential.

 

Three.

iran-blizzard

The world’s deadliest known snowstorm began this February day in 1972, lasting a full week and killing around 4,000 people. The blizzard centered on the city of Ardakan in southern Iran, the region of Shiraz, cultural capital of Iran and known for the eponymous grape. Storyteller Isak Dineson (Baroness Karen Blixen-Finecke, 1885-1962) linked that grape to urology in her short story, The Dreamers: “What is man when you come to think about him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine.” Blixen created coherent and compelling stories at a moment’s notice, and told her own life story in the 1934 book Out of Africa, that became a film in 1985 with Meryl Streep and Robert Redford. The complete passage in The Dreamers is particularly intriguing and relevant to urologists.

“ ‘Oh, Lincoln Forstner,’ said the noseless story-teller, ‘what is man, when you come to think upon him, but a minutely set, ingenious machine for turning, with infinite artfulness, the red wine of Shiraz into urine? You may even ask which is the more intense craving and pleasure: to drink or to make water. But in the meantime, what has been done? A song has been composed, a kiss taken, a slanderer slain, a prophet begotten, a righteous judgement given, a joke made…’ ”  [Isak Dinesen. Seven Gothic Tales. The Dreamers. 1934, Random House. P. 275.]

Blixen’s choice of Lincoln for the first name of one of the three central characters in her imaginative story is curious, for although it is a well-known surname it is an uncommon given name.

karen_blixen_and_thomas_dinesen_1920s

[Karen Blixen and brother Thomas Dineson on her farm in Kenya, c. 1920s. Royal Danish Library.]

 

Four.
Imagination is the ability to form ideas, images, and sensations without direct sensory input. The practice of medicine, its instruction, and its innovation demand imagination. The imagination to think through the plausibility of things, is inseparable from critical thinking. Observation and reasoning, experience and experiment, are feats of imagination that challenge dogma with new ideas in search of the best truth possible. Such creative thinking is a necessary, but often forgotten piece of the essential skeptical analysis that good physicians and scientists practice and instill in students, residents, fellows, and colleagues.

A recent Lancet article referred to the early American physician Benjamin Rush (1746-1813), who called imagination “… the pioneer of all other faculties.”

“When Rush spoke of imagination, he wasn’t talking about dragons or unicorns, he called that mental faculty fancy, and fancy had no place in medicine. Rather, Rush was talking about how the doctor’s mind gathered observations and experiences, shifting and shaping them until new truths became clear. Memory was a component of this imagination, and understanding resulted from it.” [S. Altschuler. The medical imagination. The Lancet. 388:2230, 2016.]

I’d challenge the claim that no hard line exists between those dragons or unicorns and the new ideas, hypotheses, and truths we hope to discover. Fanciful fiction, visual art, and music enrich mental milieus and provide metaphors, symmetries, dissonances, harmonies, and analogies that make clinical work and science sharper, more multidimensional, and of greater relevance than they would be without the “fancy.” E.O. Wilson infers this in his conclusion to Consilience, a book named for and about the unity of knowledge.

“The search for consilience might seem at first to imprison creativity. The opposite is true. A united system of knowledge is the surest means of identifying the still unexplored domains of reality. It provides a clear map of what is known, and frames the most productive questions for further inquiry. Historians of science often observe that asking the right question is more important than producing the right answer. The right answer to a trivial question is also trivial, but the right question, even when insoluble in exact form, is a guide to major discovery. And so it will ever be in the future excursions of science and imaginative flights of the arts.” [EO Wilson. Consilience. Alfred A. Knopf. New York.]

Creativity can also spring from irrational thought as a song in the new film La La Land suggests. Audition (The fools who dream) sung by Emma Stone: “A bit of madness is key, to give us new colors to see. Who knows where it will lead us and that’s why they need us.” Human exploration of reality requires consilience of all the tools we can muster, including scientific knowledge, historical facts, stories, and imaginative fancy.

 

Five.

puppet
When you read a story or experience visual art you may discover something new to which your brain can connect and that will illuminate other stuff in your brain at that moment or later on in reflections, dreams, or sudden denouements. Those connections provoke imagination, test reality, and elicit wisdom that affects your world view and your work. Insight and inspiration from art provide limitless opportunities in the practice, teaching, or investigation of medical care. The story of British pediatrician Harry Angelman (1915-1966) offers a minute and excellent example of illuminating connection.

“It was purely by chance that nearly thirty years ago (e.g., circa 1964) three handicapped children were admitted at various times to my children’s ward in England. They had a variety of disabilities and although at first sight they seemed to be suffering from different conditions I felt that there was a common cause for their illness. The diagnosis was purely a clinical one because in spite of technical investigations which today are more refined I was unable to establish scientific proof that the three children all had the same handicap. In view of this I hesitated to write about them in the medical journals. However, when on holiday in Italy I happened to see an oil painting in the Castelvecchio Museum in Verona called . . . a Boy with a Puppet. The boy’s laughing face and the fact that my patients exhibited jerky movements gave me the idea of writing an article about the three children with a title of Puppet Children. It was not a name that pleased all parents but it served as a means of combining the three little patients into a single group. Later the name was changed to Angelman syndrome. This article was published in 1965 and after some initial interest lay almost forgotten until the early eighties.” [Quotation from Charles Williams. Harry Angelman and the History of AS. Stay informed. USA: Angelman Syndrome Foundation. 2011.]

Giovanni Francesco Caroto (1480-1555), the Renaissance painter in Verona, created the Portrait of a Child with a Drawing and the circumstances of the subject will probably never come to light. It may well be a coincidence that the picture resembled the patients that provoked Angelman’s curiosity.

chromosomes

[Chromosome 15]

chr-15
Deletion or inactivation of genes on maternal chromosome 15 with silencing of the corresponding normal paternal chromosome is responsible for AS. Similar genomic imprinting, but with deletion or inactivation of paternal genes and silencing on the maternal side happens in Prader-Willi syndrome, that shows up more often in our pediatric urology clinics. These two conditions along with Beckwith-Wiedemann and Silver-Russell syndromes were early reported instances of human imprinting disorders. An excellent update on these conditions appeared last month in Science. [J. Cousin-Frankel. Fateful Imprints. Science. 355:122-125, 2017]

 

Six.
New residents. We just matched our new cohort of PGY1s, a stage of medical education once called internship, that starts each July to initiate the transition of medical students into specialists. The medical student is the last universal common ancestor in the evolution of a medical specialist. About 150 areas of focused practice (per American Board of Medical Specialties) are available to freshly minted MDs and those last universal common ancestors in medicine evolve into the new species of their chosen specialties during their residencies.

This educational experience is a primary reason we exist as a Department of Urology. The UMMS was formed to produce the next generation of physicians for the State of Michigan in 1850 when this mission required 2 years of medical school lectures to achieve the MD necessary to practice medicine. The medical school then needed only 5 faculty and 2 departments (Medicine as well as Surgery and Anatomy) to provide that education. Today’s world of specialty medicine requires 4 years of medical school (with lectures, laboratory work, and clinical experience) as well as graduate medical education in one of 100 areas of specialty training offered here in Ann Arbor. Our medical school faculty numbers 2500 in 30 departments. We educate, at any moment, about twice as many residents in specialties as medical students – and the period of residency training may be more than twice as long as medical school itself.

New members of the UM Urology family are: Juan Andino with BS, MBA, and MD degrees from UM; Chris Tam with BS from UC San Diego and MD from the University of Iowa; Robert Wang with BA and MD degrees from Washington University in St. Louis; and Colton Walker with BS from Stanford and MD from Louisiana State University in New Orleans. Who knows where they will lead us?

 

Seven.
Darwin & Lincoln’s birth, on the same day in the same year, was the wonderful coincidence of February 12, 1809. Two more different circumstances for those neonates would be difficult to imagine although both families had roots in England. Both men had big imaginations that changed the world in positive ways that endure today. Darwin arrived in the center of the civilized world, Shrewsbury England, to a prosperous family. His grandfather, Dr. Erasmus Darwin, was one of the great thinkers of his time and his father Dr. Robert Darwin was a successful physician. The house where Charles Darwin was born was distinguished enough to have a name, The Mount. Abraham Lincoln was born in a small primitive cabin, now long gone, on the Sinking Spring farm on the western periphery of a nation barely 33 years in existence. The nearest town, Hodgenville, didn’t even get its name until 1826, long after the Lincoln family, short on money and education, had moved on.

400px-charles_darwin_photograph_by_herbert_rose_barraud_1881

[Above: Photo by Herbert Barraud, last known picture of Darwin. 1882. Huntington Library. Below: Last known high-quality Lincoln photo, March 6, 1865. Library of Congress.]

lincoln-warren-1865-03-06-jpeg

Darwin’s idea, The Origin of Species, contained the belief that species couldn’t breed with different species. The classic example of reproductive isolation that many of us recall from childhood was the mule, the result of a donkey and horse breaking the species barrier recreationally, but the resulting progeny was sterile and incapable of creating a further bloodline. That belief in a barrier to interbreeding, or hybridization as biologists term the process, has fallen away in the new era of genomic information. The Neanderthal and Denisovan genes in the Homo sapiens genome is a rather intimate example of species interbreeding. It turns out that hybridization has played an important role in evolution throughout most kingdoms of life.  The mule is joined by the liger (lion/tiger), Hawaiian duck (Mallard/Laysan duck), red wolf (coyote/gray wolf), and pizzly (polar/brown bear). Domestic dog and wolf interbreeding has given wolves a variant immune protein gene, β-defensin, that conveys a distinctive black pelt and improved canine distemper resistance to wolf/dog hybrids and their descendants. [Elizabeth Pennisi. Shaking up the tree of life. Science: 354:817-821, 2016.] In a practical sense for our work in healthcare, bacterial swapping of DNA presents great challenges. Darwin recognized a mighty force – nearly as mysterious and pervasive as gravity – that crops up way beyond biology. Even in social ebbs and flows of life, Darwinian forces are at play, for surely they have made markets, politics, and academia increasingly creative.

 

Eight.
LUCA. Central to the multiple facets of our interests and knowledge as clinicians, surgeons, and urologists, we are ultimately biologists. In that spirit, the mystery of how life began on Earth is an irresistible intellectual puzzle and if you align to the Darwinian line of the speculation the concept of a very simple common ancestor holds traction.

Such a single cell, bacterial-like organism would have begat the three great domains of life: archaea, bacteria, and later the eukaryotes. Of the 6 million protein-coding genes in DNA data banks, William Martin et al at Heinrich Heine University in Dusseldorf speculated that 355 were present in that most primitive of ancestors, called the Last Universal Common Ancestor (LUCA). These probably originated around volcanic sea vents that supplied just the right conditions. Whether or not LUCA came from sea vents, warm ponds, or other environments should become clearer as biologists dig deeper into our roots. LUCA might have looked like any of the archaea and bacteria we recognize today with stiff walled rods or cocci. More complex shapes required the flexible cell walls that came later with eukaryotes. LUCA probably existed as an anaerobe in a vent-like hydrothermal geochemical setting and was based upon 355 genes according to a paper from the Institute of Molecular Evolution at Heinrich Heine University in Düsseldorf.

luca

[Figure from MC Weiss, FL Sousa, N Mrnjavac et al. The physiology and habitat of the last universal common ancestor. Nature Microbiology. 1, Article number 16116, 2016.]

Much has happened since LUCA. Given the Darwinian trials of variation by error in the face of minor and gross environmental challenges over millions of millennia, new species developed in fits and starts. The Cambrian explosion of new creatures was one of many responses of speciation to planetary change. We humans seem to be at the far opposite end of the phylogenic spectrum from LUCA. Our complexity is not just a matter of our biology and our cerebral skills, but no less a matter of the social nuances that elaborate the human condition.

 

Nine.
A Fortunate Man. The classic study of an English general practitioner in the 1960s, alluded to on these pages last year sharpened my perspective as a physician. [John Berger, A Fortunate Man, Random House, NY 1967.] The ancient perspective of healthcare, documented since medical recipes in ancient early Egyptian papyri and Hippocratic writings, was a matter of dualities: one patient-one physician, one problem-one solution, and one teacher-one student. This changed in the past century due to medical specialties and technology that have introduced unmeasurable complexity. Patient care and medical education are no longer two-body problems, but are now part of a multidimensional healthcare matrix.

Even that multidimensional professional matrix is dwarfed by the complexity of patients with their own multidimensional physical, mental, familial, social, economic, political, and environmental comorbidities. You might lump all these comorbidities together and simply call them “the human condition” that Berger probed in A Fortunate Man, hinting that we really have little sense of what our patients are all about. However, as we practice our art, we become better at understanding the holograms of the patients as they present themselves in our clinics even in the short time frames at hand and the insistence of electronic health records and economics that force us to default to two-body problems (augmented with a few clever comorbidities that can permit a more realistic billing code).

Berger died last month (January 2) at 90 in the Parisian suburb where he lived. I didn’t know much about him since I read his book just last year (and I wish I could remember who told me to read it). Berger (pronounced BER-jer,) was known as a “provocative art critic” in the obituary by Randy Kennedy that included this example:

“He was a champion of realism during the rise of Abstract Expressionism, and he took on giants like Jackson Pollock, whom he criticized as a talented failure for being unable to ‘see or think beyond the decadence of the culture to which he belongs.’” [Kennedy. New York Times Tuesday January 3, 2017.]

The obituary ran for three columns and mentioned a number of Berger’s books, but not A Fortunate Man.

 

Ten.
That other birthday celebrant of February 12, 1819, would also have been 198 years old this month. Human biology at its best wouldn’t have given Lincoln that chance, but it was political extremism that cut him down short of his potential fourscore and ten years. While Darwin’s ancestors provided more than a hint of greatness for their descendent, Lincoln’s ancestry offered no such clue, but his insatiable drive for education and personal distinction contrasted remarkably with the rest of his family. His improbable success in law and politics leveraged his even more unlikely ascent to the presidency of the United States. No one could have predicted that his ultimate comorbidity would have been an actor with a Philadelphia Derringer at Ford’s Theater on April 14, 1865.

currier-ives

wilkes_booths_deringer

rimfire-cartridge

[Top: Currier & Ives print of assassination April 14, 1865. Middle: The actual Derringer. Bottom: 0.41-caliber Rimfire cartridge.]

Lincoln’s assassin jumped to the stage and escaped on a horse waiting near the backstage door. The following day he stopped near Beantown, Maryland (now Waldorf) seeking treatment at the home of Dr. Samuel Mudd, an acquaintance, for a broken left fibula. Mudd cut off Booth’s boot, splinted the leg, provided a shoe, and arranged for a local carpenter to make a pair of crutches. After catching some sleep at the doctor’s house Booth travelled on to Virginia where he was caught and killed on April 26. Mudd was arrested, charged with conspiracy, and imprisoned at Fort Jefferson in the Dry Tortugas. He tried to escape once, but became a good prisoner and was released after pardon by President Andrew Johnson on March 8, 1869. Mudd returned home to Maryland where he lived until January 10, 1883 dying of pneumonia at 49 years of age. Mudd’s grandson, Dr. Richard Mudd, unsuccessfully petitioned a number of presidents (Carter and Reagan) and also failed in other avenues to clear the family name of the stigma of aiding Booth. The family name remains Mudd.

600px-booth_escape_route-svg

[Booth escape route. Wikimedia Commons. Courtesy, National Park Service.]

Our world has changed enormously since Lincoln’s time. The American democracy is better, healthcare  is more effective, and the Earth even when viewed from far out in our solar system looks amazingly different (below); Edison’s electrical illumination, invented in 1880, has impacted both the visible planet and environment due to the fossil fuel consumption for those lights.

earth-earth-at-night-night-lights-41949

A short book on Darwin and Lincoln, Angels and Ages by Adam Gopnik [Alfred A. Knopf, NY 2009] noted:

“What all the first modern artists, from Whitman to van Gogh, have believed is that, for whatever reason, and however it came to be, we are capable of witnessing and experiencing the world as more than the sum of our instincts and appetites. Our altruism is not simply our appetites compounded; our appetites are not simply our altruism exposed. ‘Reason … must furnish all the materials for our future support and defense,’ Lincoln said, and reason alone can point us to its limits. We can argue about anything, even about the nature and meaning of our mysticisms. [Kenneth] Clark called our liberal faith ‘heroic materialism’ and said it wouldn’t be enough. Human materialism or mystical materialism, is closer to it, and it remains the best we have. Intimations of the numinous may begin and end in us, but they are as real as descriptions of the natural; Sunday feelings are as real as Monday facts. On this point, Darwin and Lincoln, along with all the other poets of modern life, would have agreed. There is more to a man than the breath in his body, if only on the hat on his head and the hope in his heart.”

 

[Footnotes: Numinous = inspiriting spiritual or awe-inspiring emotions. Mystical = having spiritual meaning neither apparent to sense or obvious to intelligence.]

 

 

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

2017 is here

DAB What’s New January 6, 2017
Free, efficient, and equal government
3752 words

 

grand-rounds

One.

Let’s not leave 2016 without a few comments about December. At Grand Rounds Andrew Peterson, visiting professor from Duke, and Daniela Wittmann gave excellent presentations on urologic cancer survivorship. Andrew explained his remarkable survivorship/reconstructive fellowship in Durham and Daniela gave a 10-year review of our uniquely successful Brandon survivorship program.

galens

Medical students raise money for our Galens Society annual “Tag Days” in early December. Founded in 1914, Galens supports Mott Children’s Hospital and other organizations that benefit children in Washtenaw County. [Above: Paul Cederna of Plastic Surgery with MS1s Alex Tipaldi and Michael Klueh at the Taubman 2 Urology ACU.]

holiday-party

Our holiday party at Fox Hills entertained over 350 people with the expected surprise of Santa who had gifts for all the children (above). Pat Soter, her husband Jim, as well as Sandy and Bob Heskett, did the heavy lifting for this event and we thank them. Pat’s retirement leaves a major challenge filling her shoes. A faculty evening meeting (below) discussed residents progress, urology divisions, strategic planning, and John Stoffel’s stint as Acting Chair.

fac-mtg

Now that we are 6 days into 2017, Happy New Year from Michigan Medicine’s Department of Urology.

 

 

Two.

Liberty, once attained, is taken for granted. We grieve its loss, fight for it, but are not good at maintaining it. On this day in 1941 Franklin D. Roosevelt delivered his Four Freedoms State of the Union address. Pearl Harbor would happen 11 months later. FDR came to the presidency in turbulent times and became enormously popular, serving nearly 4 terms. Some people disparaged his social policies, yet few disputed his belief in essential freedoms: freedom of speech and expression, freedom of worship, freedom from want, and freedom from fear.

washington

[Washington @ Delaware. Sully 1819. Boston Fine Arts Museum]

The State of the Union address is prescribed by Article II Section 3 of the U.S. Constitution. George Washington gave the first to Congress in New York City on January 8, 1790, 9 months into office. The new government had recently come to power after 11 of 13 states accepted the Constitution, but North Carolina waited to ratify, pending a Bill of Rights. Washington’s address, praised North Carolina’s acceptance two months earlier. (Rhode Island became the last of the 13 original colonies to ratify, later that year on May 29.) That first State of the Union address at 1089 words (page 1 below) is shorter than any of its successors.

Washington set the tone in the opening sentences.

“Fellow Citizens of the Senate, and House of Representatives. I embrace with great satisfaction the opportunity, which now presents itself, of congratulating you on the present favourable prospects of our public affairs. The recent accession of the important State of North Carolina to the Constitution of the United States (of which official information has been received) —the rising credit and respectability of our Country — the general and increasing good will towards the Government of the Union —and the concord, peace and plenty, with which we are blessed, are circumstances, auspicious, in an eminent degree to our national prosperity.”

The conclusion was optimistic.

“The welfare of our Country is the great object to which our cares and efforts ought to be directed. And I shall derive great satisfaction from a co-operation with you, in the pleasing though arduous task of ensuring to our fellow Citizens the blessings, which they have a right to expect, from a free, efficient and equal Government.”

We anticipate President Trump’s State of the Union will seek reconciliation of political polarities without yielding on core issues that decided the election. Healthcare will be heavily weighted to the legislative agenda of Paul Ryan and operational agenda of HHS head Tom Price (UM alumnus and orthopedic surgeon).

 

 

Three.

Year 1 UMMG. The ability to practice and innovate in healthcare drew many of us to medical careers, but these freedoms have become constricted. Specialization, systemic organizational impingements, economics, and regulation drive much of the constriction. Some laws restrict conversations between patient and physician, as if healthcare providers were agents of government rather than citizens with first amendment rights (after all, free speech was first in the Bill of Rights).

Consumer discontent over healthcare delivery dominates the news, but discontent from the perspective of practitioners is equally important; dissatisfaction within healthcare professions affects delivery, efficiency, education, innovation, and pipeline of future practitioners. We can’t solve all the national and regional healthcare problems from Ann Arbor, but we can influence their solution and serve as a best-of-class example.

The structure, governance, and policies of the UM Health System have re-assembled over the past year. Our new Michigan Medicine governance is certainly less monumental than Washington’s new union in 1790 and contains key differences. Whereas the US federal system depends on a three-way balance of power, Michigan Medicine intends an integration of authority. “Silos” that evolved over the past 150 years at UM – namely the Medical School (UMMS) and its faculty, clinical departments, hospital administrative structure, and research enterprise – while related and sharing many of the same people, often worked at cross purposes to defend budgets, becoming archipelagos of cost centers.

One year ago the UMMS and its Health System merged the positions of Dean and EVPMA (Marschall Runge). Three vice dean positions were created: Clinical Vice Dean/President of UM Health System (David Spahlinger), Academic Vice Dean (Carol Bradford), and Scientific Vice Dean (TBD). A new UM Hospital Board with healthcare expertise and regental participation will oversee the entire health system and medical school.

The re-organized health system has 3 main operating units: Hospital Group I (Main & CVC), Hospital Group II (Mott & Women’s), and the UM Medical Group (UMMG, formerly the Faculty Group Practice = FGP) that manages ambulatory practices as well as regional affiliations. In the 2007 FGP, UM ambulatory activities were divided into 90 Ambulatory Care Units (ACUs) intended to function under local control by the healthcare providers to maximize lean principles. The ACUs have grown to 150 and Timothy Johnson was just named UMMG Executive Director. Tim ran the Multidisciplinary Melanoma Program, served as Division Chief of Cutaneous Surgery and Oncology, led the very successful Mohs Ambulatory Care Unit director, served as training director of the ACGME fellowship in Micrographic Surgery and Dermatologic Oncology, and is the Lewis and Lillian Becker Professor of Dermatology.

tim-johnson

Tim’s skin cancer programs involve over 25 departments, divisions, service lines, and centers, and consistently earn superb ratings of patient satisfaction, employee engagement, and access. His programs  generate significant grant funding, publications, and clinical trials.
New governance structure, expanded facilities, and growing affiliations should allow Michigan Medicine to carry out its missions no matter how the greater US healthcare system evolves. The UM has a history of innovative morphology beginning in 1869 when a faculty house became a hospital – the first occasion for a university to own and operate a hospital. While this originally happened for the purpose of teaching, the mission evolved to become a conjoined one of education, research, and state-of-the-art clinical care.

 

 

Four.

Inclusion of a hospital within the Medical School, extended medical education from classrooms to bedsides, a first step in building the UM Health System. Clinical and investigational laboratories later brought science into medical education and created new opportunity for investigation and innovation. An ambulatory care building in 1953 and offsite clinics carried UM into outpatient healthcare that is now expanding into homes, workplaces, and other daily living spaces of patients. This fourth dimension of healthcare (1=classroom, 2=bedside/OR, 3=ambulatory clinic, and 4=patient life circumstances) complements health services research, as practiced in our Dow HSR division, opening doors between medical schools and schools of public health, pharmacy, natural resources, nursing, kinesiology, and sociology. Our North Campus Research Center (NCRC), acquired from Pfizer, facilitates integration of all healthcare dimensions. [Below: David Canter Executive Director NCRC & Marschall Runge]

runge-cantor

 

 

Five.

Polar arguments related to the future of health care are being fought simultaneously in political battlegrounds and marketplaces. One argument is that health care is “too expensive” and we often hear that “we’re giving too much away.” The other argument was summarized in The Lancet cover quotation just before the November election: “Whichever way the election goes, one issue is certain: the next president of the USA will inherit a country in which deep health and health-care inequalities exist along multiple lines, including income, race, and gender.” [Editorial. “America decides.” The Lancet. 2016; 388: 2209]

There is little doubt that healthcare as deployed today is expensive and many factors account for this, significantly the insurance-based paradigm, corporatization of healthcare, and regulatory costs. Fee-for-service (FFS) factors and waste in the system are also blameworthy. Although both can be mitigated, waste will never be eliminated in human processes and FFS always finds a place in any free society. When people complain that too much is being given away, they are likely referring to suspicion that “other people” benefit from services that they, as taxpayers, support. This sense of unfairness is deeply seated.

Just as deeply seated at the other pole of belief is outrage over the unfairness of healthcare disparities. The right to healthcare, many will argue, is essential to life, liberty, and the pursuit of happiness, ideas deeply ingrained in American civic belief. No less important is the fact that it is in the public interest for everyone to have a basic level of health care. It is in your interest that the person next to you, next to your family members, next to your colleagues, and next to your friends – whether on the street, in a store, at a restaurant, or on a plane – doesn’t have TB, measles, Ebola, or some other communicable disease. It is in all of our interests that air and water quality are good. It is in our interest that violently mentally ill people are not disrupting work places or driving on streets. It is in your interest that homeless people have health care. Every civilized country recognizes some national responsibility to provide health care, differing mainly in the mechanisms and extent of coverage.

Reconciliation of these polar beliefs is a political problem, an economic problem, and a public policy problem. No simple solution or model will likely satisfy all these problems and beliefs. The public wants availability, affordability, and quality, but finds it easier to provide any two of these attributes instead of all three.

 

 

Six.

Federally Qualified Health Centers (FQHCs) provide one avenue to health care. These community-based organizations target underserved health care needs. Established to provide comprehensive health service to the medically underserved and reduce emergency room care, the FQHC mission has shifted to enhance health care services for underserved, underinsured, and uninsured individuals in urban and rural communities. Care is provided to all patients, including migrant workers and non-US citizens, regardless of ability to pay, based on sliding-fee scales established by FQHC community boards. In return for serving all patients FQHCs receive government cash grants, cost-based reimbursement for Medicaid patients, and malpractice coverage under the Federal Trot Claims Act (FTCA) of 1946. The ACA set aside $11 billion dollars over 5 years to cover FQHC costs. FQHCs serve one in 13 people in this country.

Some of the approximately 2000 FQHCs in the US are small operations, while others like the Hamilton FQHC in Flint are substantial enterprises. Two federal agencies oversee FQHCs. One is the Bureau of Primary Health Care, under the Health Resources and Services Administration (HRSA). The other is the Centers for Medicare and Medicaid Services (CMS), also under the Department of Health and Human Services (HHS). The Health Center Consolidation Act of 1996 (commonly called Section 330) brought together funding mechanisms for community health facilities, such as migrant/seasonal farmworker health centers, healthcare for the homeless, and health centers for residents of public housing. Previously, each of these organizations was provided grants under other mechanisms.

The Bureau of Primary Health Care is a part of the Health Resources and Services Administration (HRSA), of the United States Department of Health and Human Services. HRSA helps fund, staff and support a national network of health clinics for people who otherwise would have little or no access to care.

The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (HHS) administering the Medicare program and partnering with state governments to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments, and oversight of HealthCare.gov.

 

 

Seven.

hamilton

The Hamilton Community Health Network (HCHN) began in 1982 as the Hamilton Family Health Center under St. Joseph’s Hospital (now Genesys Health System) in response to unmet healthcare needs in Flint, Michigan. Moving to the present site (now the administrative headquarters shown above) in 1988 it began receiving federal funds to provide healthcare for the growing homeless population. Becoming HCHN in 2001 the organization assumed financial and operational responsibility from Hurley Hospital for primary and preventive care at the hospital’s North Pointe facility, and the following year began operations at a combined medical-dental site in partnership with the Genesee County Health Department. Hamilton, now a part of a national network of primary care centers (Section 330E), provides comprehensive healthcare services for underserved urban, rural, and homeless populations in addition to operating a family medicine residency program under HSRA funding since 2014. Hamilton has 6 clinical sites: the Main Clinic, the Burton Clinic, the Dental North Clinic, the Clio Clinic, the Lapeer Clinic, and the North Pointe Clinic. The Main Clinic is a new $5 million facility of 31,000 square feet, funded by federal dollars, local grants, a capital campaign, and debt that has been totally paid off.

The pairing of urology and primary care practices is natural. The Hippocratic Oath 2000 years ago recognized the unique nature of urologic expertise and the need for specialists. Every human being will have urologic issues of one sort or another and there will never be enough urologists to “go around.” Working side-by-side with primary care providers, urologists can teach them, just as they can teach urologists, providing comprehensive health care where and when it is needed.

ham-board

[Above: Hamilton FQHC in Flint: Board of Directors. Below CMO Mike Giacalone Jr., CEO Clarence Pierce]

mike-clarence

The UM Urology Department began clinics at Hamilton in 2015 working with an excellent clinical team including a superb physician’s assistant Ben Busuito (below). Urology clinics are now staffed nearly every week by myself, John Wei, John Stoffel, Anne Pelletier Cameron, Ganesh Palapattu, Meidee Goh, Chad Ellimoottil, and Gary Faerber – who has been coming back periodically from Salt Lake City. Our faculty have never been assigned to Hamilton nor subsidized to travel to clinics; we simply created the arrangement and our urologists saw the need and the opportunity. My clinic at Hamilton is streamlined for patients and providers, so my time in Flint is also a learning experience to improve our UM ACUs.

ben-team

[Clinic team: Melanie Slackta, Alice Yanity, Ben Busuito, Michelle Durall, Michelle Williams]

 

 

Eight.

True facts. Legendary professor Don Coffey at Johns Hopkins often admonished trainees: “You have to understand the difference between facts and true facts,” advice that resonates with me in this new milieu of fake news on social media. Don taught the importance of critical thinking and insistence on truth. The truth matters in science, in politics, and in all human interactions.

American philosopher Harry Frankfort wrote an important book entitled indelicately, but appropriately, On Bullshit (Princeton University Press, 2005) and this demanded a sequel the following year, On Truth (Alfred A. Knopf, 2006). Both books are worth your attention. (friend at Emory gave me a copy of the former book). If you’ve read them once you should read them again. True facts seem to have diminished influence today and false news is on the rise. Expect change in 2017. Worldwide social media communication will drive much of it, but dig critically for truth and its impostors.

orson_welles_war_of_the_worlds_1938

[Oct. 31, 1938: Orson Wells telling reporters no one expected the broadcast would cause public panic. Acme News Photos. Wikipedia]
The infamous War of the Worlds radio play in 1938 is a cautionary tale. The HG Wells story was directed and narrated by Orson Wells (no relation), but listeners who tuned in after the introduction misinterpreted the play as an actual alien invasion. Modern social media technology has increased the ease of dissemination of erroneous stories or deliberate manipulative propaganda. A single false story or conspiracy theory can spread around the planet in minutes to reach a sizable part of our 8 billion gullible global citizens. With print media and professional journalism on the decline, the world is dangerously vulnerable to manipulation by a random or purposeful catalyst.

The best defense against tomorrow’s War of the Worlds will be based on two foundering, elements of civilization. One is education – teaching critical thinking skills. That education needs to begin in grade school and sharpened later on the educational ladder in math, physics, physiology, and pharmacology just as well as in English, art history, or architecture. Broad critical thinking needs to continue in professional schools, graduate medical education, and beyond in our jobs and communities. The other element is a multiplicity of robust, trusted, and critical media sources providing timely scrutiny and analysis – and these are the fourth and fifth estates.

 

 

Nine.

Medieval social power structure can be conceptualized to three estates of the realm, namely the clergy, the nobility, and the commoners. The American colonies that united under George Washington disrupted that traditional model to create representational democracy and it is no mere coincidence that one of its early builders was a printer, Ben Franklin. Imperfect as it was and is, representational democracy surpasses anything else that has been attempted for civilized governance, but it demands an educated populace and continuous vigilance by the press, known as the fourth estate.

The immediacy of social media led to the concept of a fifth estate, consisting of web-based technologies. Curiously, that was the name of a countercultural underground newspaper, first published in 1965 in Detroit. The first issue included a review of a Bob Dylan concert, a “borrowed” Jules Feiffer cartoon, and announcement of a march in Washington. The periodical remains active and is believed to be the longest-running anarchist publication in English. The Fifth Estate archives are held here at the University of Michigan in the Labadie Collection at the Harlan Hatcher Library. [Below: First page first edition Nov 19-Dec 2, 1965. Courtesy UM Labadie Collection & Julie Herrada]

fifth

————————————————–

What’s New/Matula Thoughts, this particular small-scale electronic posting, was intended as monthly essay for colleagues and friends. It has worked its way around the global village although we can’t track the What’s New email version that gets forwarded beyond its initial recipients, we can track the MatulaThoughts website version through WordPress analytics.

stats-mid-dec

[Above: MatulaThoughts analytics in mid-December]

Most web postings of this sort feature short blurbs linked to aggregated articles that may, or may not, contain verifiable reporting or critical analysis. MatulaThoughts differs in that its 10 items contain some streams of continuity, random observations, and specific references usually to scientific literature. Striving to keep this under 4000 words, we view this as a monthly essay for Michigan Urology family and friends, recognizing that while many find time for only a cursory scan, others pick out one or more items to read more carefully. Some readers around the globe, however, read this better than I write it, and communicate back related observations, different opinions, or find mistakes I’ve made. My thanks, especially, to those critical analysts.

 

 

Ten.

The Fifth Estate, just as the fourth, was heralded as a boon to free speech, human liberty, and democracy. Outrageous claims or gross propaganda, however, bring a perverse twist to social media, abetted by public tolerance and even an appetite for fake news. The boundary between fake news (mainly enjoyed as entertainment) and true factual news is indistinct and the difference doesn’t seem to matter to many people. This imperils democracy for it cannot be doubted that truth matters in a free and civilized society. Social media can provoke a presumably rational person to enter a church and open fire on parishioners, to take weapons to “investigate” restaurants in distant cities, to target-shoot highway drivers, or “execute” policemen in their cars. The truth matters to all of us. Its distortion undermines civilization.

Truth matters in science and is absolute in the health professions. Deception in the reporting of a blood test, cut-and-pasted notes, conversations with colleagues or patients, or manipulated scientific results may sneak by in the workplace or in the literature for periods of time, but eventually get discovered and demand public scorn and long-standing distrust. One rascal, even among thousands of “honest brokers” diminishes the public trust. Trust matters in engineering, construction, food safety, nuclear power plants, the transportation industry, water standards, air quality, and so on. It matters too in journalism, law, politics, and life in a cosmopolitan world. Purposeful exploitation of truth, whether self-serving lie, propaganda, or mischief should be called out. A related deception is that of careless or deliberate plagiarism, when another person’s distinct intellectual property such as sentences, images, etc. are claimed as one’s own.

How then can we distinguish these threats to free speech from fiction? To me, fiction is the art of creating a story that entertains and may give insight to our lives. The proper purposes of fiction (that is, the purposes that civilized and educated people should accept) are distinct from propaganda, deception, and plagiarism.

Freedom of speech carries with it the responsibility to be critical and intolerant of gross distortions. Preservation of the freedoms we claim as humans (namely, life, liberty, and the pursuit of happiness) demands an attention that in this country we elevated to a cabinet-level status under Dwight Eisenhower in 1953. This was the Department of Health, Education, and Welfare (HEW) with the motto, “Hope is the anchor of life.” In 1979 the Department of Education was split out and HEW became the Department of Health and Human Services (HHS). These organizations have spent much taxpayer money and have done great good, but are complex and imperfect. These have been, I believe, the only cabinet-level departments created by presidential reorganization. The ability of the president to create or reorganize bureaucracies, as long as neither house of Congress passed a legislative veto, was removed after 1962. Fifteen executive cabinet-level departments currently exist.

hew-seal

[Above HEW seal; below HHS seal]

hhs-seal

Although seemingly arcane, these matters demand our attention for a free, efficient, and equal government.

 

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

Matula Thoughts December 2, 2016

Politics, nutcrackers, and earthly delights
3799 words

One.

election-2016-copy

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

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

herblock1950

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

castro

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

 

 

Two.

colors

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

baa

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

supermoon

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

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

snowy-4th

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

 

 

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

el_jardin_de_las_delicias_de_el_bosco-1

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

van-leyden

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

 

 

Four.

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

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

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

 

 

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

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

lange

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

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

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

 

 

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

 

 

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

peterson-tim

 

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

 

 

Eight.

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

nutcracker

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

 

 

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

house-of-cards

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

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

 

 

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

repub-pres

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

political-promises-copy

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

 

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

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

Castling

DAB Matula Thoughts Nov 4, 2016

 

Matula Thoughts Logo2

3975 words

Preface. This monthly communication from the University of Michigan Department of Urology & David A. Bloom is usually sent by email or posted on line at matulathoughts.org on the first Friday of each month.

huron

One.  

Autumn has been spectacular at Michigan Urology academically and around Ann Arbor visually. Seasonal changes on the Huron River were up to high expectations as leaves colored out and birds headed south. You don’t have to travel far outside of town to see crop harvesting has wound down, while distracting political signs along the roads are highlighting our national political schizophrenia. [Above: Huron River near Wagner Road. Below: Waterloo Road east of Chelsea, Michigan]

silo

 

Nestled in the Midwest, we were spared Hurricane Matthew that hit Haiti, Florida, Georgia, and the Carolinas in October. The biggest regional surprise was the overtime World Series victory of the Chicago Cubs over the Cleveland Indians, both teams having contested well. Births and other happy events also perked up this season, but we suffered losses. Madeline Horton, secretary of Jack Lapides and mother of Suzanne Van Appledorn (wife of Carl Van Appledorn, Nesbit 1972) passed away last month a few weeks short of her 100th birthday. Madeline was our urology librarian, a job largely obviated by the internet. I fondly remember her gracious welcome when I joined the University of Michigan Section of Urology in the early years of Ed McGuire’s leadership.

Final rules for the Medicare Access and CHIP Reauthorization Act (MACRA) went into effect last month, instituting the Quality Payment Program (QPP) that begins its first performance period 58 days from now, by my count. This will significantly change the basis of physician payment and the rules are entrenched so deeply in federal regulation as to be practically bullet-proof from the impending presidential election or other short-term political processes. By November, it is pretty clear that another calendar year is coming to an end and it’s time to start serious planning for next year. Of course as a department of urology specifically, and as a large academic health center more generally, our planning has been on going in earnest for considerably longer than the past few days. Emerging out of many years of restricted capital investment in facilities and regional relationships we are in an unprecedented growth mode to more optimally fulfill our mission. This has been the first year of our new organizational paradigm for the University of Michigan Health System in which Executive Vice President for Medical Affairs of the University, Marschall Runge, added the Medical School deanship to his portfolio. A Health System Board along with Health System President, David Spahlinger, will manage the growing enterprise of hospital groups, medical practice, ambulatory clinics, regional affiliations, and other entities that have evolved to carry out our mission. These are good structural changes and superb individuals for the challenges ahead.

Our mission derives from our foundation as a public medical school in 1850 and is similar to the mission of all other medical schools, although the University of Michigan has long described itself as one of the “leaders and best”, a phrase that history shows we can rightly claim, for the most part. The mission is framed around three components – education, patient care, and research – deployed in that order as our medical school grew, adding its own contained hospital in 1869 and soon thereafter some of the world’s definitive basic science departments and research laboratories.

 

 

Two.  

Silos of expertise necessarily accrued as the medical school and health care center in Ann Arbor grew more complex with the result that the overall management became increasingly disconnected from the loci of expertise at its many workplaces. The gemba, a Japanese term related to the Lean Process Methodology of the Toyota Corporation, describes where work is performed – the workplace. As Toyota, and later Detroit automotive manufacturing came to understand, microeconomic gembas understand their products, customers, and processes better than higher-level managers or accountants. Process improvement, value creation, efficiency, customer satisfaction, and employee satisfaction are best arbitrated “where the work is done” (i.e. the gemba) rather than in distant offices by managerial accounting.

Oddly, just as forward-thinking western businesses are embracing lean process thinking, large health care systems and governmental organizations are more rigidly holding on to managerial accountancy with its concomitant archipelago of cost centers. Of course any organization needs to understand and mitigate its costs, but lean process experience has shown that efficiency and value are a natural result of letting the gemba work as an organic community, rather than forcing its functions by the levers of managerial accounting. [Below: going home from work, a Diego Rivera mural detail – Detroit Institute of Arts]

dsc03595

Anyway, back to the triple mission: the University of Michigan Health System exists to educate the next generation of physicians and scientists, to expand the knowledge and technology base of health care, and to do these things in a milieu of cutting edge clinical care. The central organizing principle at play, that is the essential deliverable (and moral center) is kind and excellent patient-centered care, as we describe it in our department.

The future in healthcare will depend on our ability to weave silos together and innovate, creating new ideas, devices, and methods. In a larger sense innovation is the ability to find better solutions for the needs of a changing environment.

 

 

Three.          

Leadership.  A recurring aspiration of the University of Michigan is that it produces the “leaders and the best.” That phrase is functionally adjectival as with the leaders and the best engineers, teachers, athletes, lawyers, nurses, chemists, or physicians, for example. The leaders and best is less meaningful as a noun, for what does it really mean to be “the best” if not the best of some particular thing. The same holds true for leadership, in my opinion. The aspiration to be “a leader” as a generality carries a bit of a selfish sense with it, whereas the aspiration to lead one’s team to do its job well or otherwise fulfill its mission is more socially virtuous. The difference is perhaps one between the captain of a football team versus travelling CEO’s who jump among companies to exercise their managerial or accounting gifts. Without deep knowledge and investment in a particular organization, an itinerant leader is unlikely to inspire most organizations and its people to achieve their best social destiny. Another way to look at this is whether the leader’s primary goal is to be “the boss” by leading, managing, and controlling employees to achieve organizational targets, in contrast to a goal of helping the organization achieve an optimal state for its stakeholders.

What does a urology department need in a leader? I submit that first and foremost it needs someone who loves and practices urology robustly; former dean Allen Lichter once said  – “for such a person patient care is a moral imperative, not something that is important enough unless it interferes with research.” Second, a clinical department needs an individual who understands the organizational mission and its history – these two things are inseparable, requiring more than just lip service to be truly known. Third, we require someone whom the faculty, residents, staff, and other stakeholders trust. Fourth, the department needs a person who can read the changing environment and find opportunities within it. Other attributes may be valued according to the specifics of each department, institution and moment in time, however “celebrity leadership” by itself should not be high on the list of qualities sought.

 

 

Four.                 

bruxelles_manneken_pis        

Until it fails, people don’t appreciate the beauty of a competent urinary system. Urologists are the essential attendants at that particular service station of life, but the necessity of professional detachment renders us susceptible to underestimating the angst and vulnerability of urologic patients. Finding the right balance between empathy and detachment is a personal matter, arbitrated by daily experience to the extent that we are influenced by our medical practices, role models (real and fictional), and general observations in life. To the extent that we pay attention to the real world around us and to the creative arts, we improve our practice of medicine.

Creative arts matter to medicine. The portrait of Dr. John Sassall by Berger & Mohr in A Fortunate Man, was an artful mix of empathy and detachment. The doctor had sufficient detachment to do what he needed medically for his patients, but retained unusual empathy for their social and economic comorbidities, even to his personal detriment.

In the visual arts for hundreds of years urinalysis, depicted by uroscopy flask (the matula), was the main symbol of medicine indicating the central importance of urine examination to understand disease. After 1816, when Laennec invented the stethoscope, the matula lost its place as the popular symbol of the medical profession. The stethoscope is certainly a less indelicate and a sturdier symbol than a glass urine flask. Imagine Gray’s Anatomy with the matula.

In literature Shakespeare was precocious in recognizing the fallacy of mistaking a clinical test for the actual patient when in this scene from Henry IV Falstaff asks a messenger what the physician thought of his uroscopy specimen:

“Sirrah, What says the doctor to my water?

He said, sir, the water itself was a good healthy water;

But for the party that owned it, he might have more diseases than he knew for.”

Visual art has only rarely portrayed urinary function. One example, the statue Manneken Pis (Little Man Pee, in Dutch. Above: Wikipedia illustration) designed by Hieronymus Duquesnoy the Elder around 1618-1619 has been stolen numerous times and the current version, dating from 1965, stands in Brussels. It is dressed in costumes according to a published schedule managed by “Friends of Manneken-Pis,” but I don’t know if University of Michigan colors have adorned it yet. Other versions of the statue exist regionally and in more distant sites in the world. Notice the arching back of the confident lad making his momentary mark on the world in front of him.

Depiction of urinary tract dysfunction in art is even less common than that of normal function. As common as dysuria and stranguria are for us humans, it’s rare to find them represented in the creative world. The Wayfarer, by Bosch, shows a man with the hunched-over posture typical of urinary distress, relegated to the central background of this curious painting. The painter, who died 500 years ago, lived in the historic low countries now called the Netherlands where he no doubt observed that characteristic posture often, as we do today in restrooms around the world.

the-wayfarer-large

[Hieronymus Bosch. Above: The Wayfarer. Below: voiding detail.]

bosch-detail

The impact of nocturnal enuresis showed up in All’s Quiet on the Western Front, where a young soldier suffered with that burden.

My point is that creative arts sharpen our perception and groom our mirror neurons to make us better attendants at life’s service stations.

 

Five.              

Castling. A few months ago this column referred to Richard Feynman’s metaphor related to mankind’s persistent search for central organizing principles, namely our curiosity to discover rules that govern the universe. He noted that, as we observe the “chess game of the world” and try to figure out how it works, every now and then “something like castling” occurs and blows our minds. That particular chess move is so far out of the box with respect to the other orderly rules and procedures of the game that it is, indeed, something of a miracle in that environment. (For chess aficionados the term rook may be preferable to castle, although castling sounds more appealing than rooking.)

castmove

It is human nature to seek rules. Prehistoric tribal priests, Ionian philosophers such as Aristotle, and recent scientists such as Feynman sought central organizing principles and rules. Unlike the explanations of the village priests, today’s principles of math, physics, chemistry, and biology are testable and verifiable or refutable. We have some ideas of why and how inorganic material things need to flow or seek equilibrium – principles of physics and chemistry govern their existence and fate. It is more of a mystery why biological things need to grow and humans, in particular, need to know things. No one has figured out, without invoking magical or religious paradigms, why our particulate niche in the universe is such as exception to what we perceive as the second law of thermodynamics. Perhaps our material, biological, and intellectual exception to the expanding and entropy-seeking universe is that strange miracle of “castling.” Bob Seger and The Silver Bullet Band expressed it more poetically in the 1980 song Against the Wind.

alaska

[Cosmic castling. Copper River. Kenai Peninsula, Alaska. Summer 2015]

 

 

Six.

It may seem an overstatement of human optimism to believe in the principle that the world you imagine is the world you are most likely to create, but a single person can have remarkable impact; Joan of Arc, Harriet Tubman, Abraham Lincoln, and Mahatma Gandhi are just a few examples. The impact of a single person, just as likely, can be darkly retrograde and numerous examples quickly come to mind.

Scientific thinking and modern technology have given mankind unprecedented tools to change the world with Albert Einstein and Steve Jobs as two of a myriad of other players. If you imagine a kind and just world, you will likely try to live by and spread those attributes. If you imagine a dog-eat-dog world and display that vision to those around you, that may likely become the reality you experience and leave behind. The possibility that a given leader can be good or bad for humanity might appear statistically random, that is stochastic, in terms of probability. On the other hand, if we carry the theme of castling to the idiosyncratic human experiment, it may not be so far-fetched to suggest that our genetic and epigenetic construction has built in a predilection to favor good over evil, making an individual more inclined to do the “right” rather than “wrong” thing at a given moment. That is, the elements leading up to a given personal decision are built upon individual upbringing, world-view, personal needs, perceived needs of our clan, and hope for the future. Adding all these elements, our prevailing human nature favors doing good, in the stoichiometric sense, most of the time.

 

 

Seven.

Where American health care will go next is unclear, no matter how the presidential election turns out next week. Problems abound in health care. The interface between patient and provider filling up with busy work and costs that distract from quality, safety, value, or satisfaction. Third party payers, regulators, public policy (even if well-intentioned) add an immense amount of “stuff” to be done before, during, and after the so-called patient encounter. While we prize innovation and the rewards of a free society, egregious exploitation of American healthcare consumers by industry seems to be getting worse and fuels demands for significant change. The EpiPen disgrace from the Pennsylvania company Mylan is only one of the many recent examples of human elements gone bad [JAMA 316:1439, 2016]. Why call out that one bad example among so many? My reason is simply that Mylan has made themselves such an easy target because they have been so sociopathically greedy.

Our urology silo has been a good one locally and internationally, by and large. This is evident now in the midst of the residency selection process wherein we advocate for our particular training program in Ann Arbor, our specialty having attracted many of the best and brightest of this year’s senior medical students. My colleague and friend Mike Mitchell once called urology (pediatric urology, in particular) “a lovely specialty.” We practice at the cutting edge of technology, we improve patient lives, we fix things that are broken, we have the gift of long relationships with patients, and we generally get along well within our professional arena. As a medical student and resident myself, years ago, the attributes and role models of urology attracted me into the field – and these features of our profession continue to attract the superb students and residents to follow us.

Healthcare is changing and the urology of tomorrow will differ from what I experienced in my career. We have already transitioned from roles as independent urologists such as that of our predecessors Hugh Cabot, Reed Nesbit, and Jack Lapides. Our work to educate, treat patients, and expand the knowledge base of urology requires subspecialization and teams, large teams that transcend clinics, offices, department, and operating rooms. The complexity of science, technology, and healthcare delivery made this change inevitable, with marketplace pressures and regulatory actions accelerating change. The fee-for-service that largely defined health care over the past century is being rapidly displaced by alternate payment methodology, with a sharp focus on value and performance in play today. These were vague terms in health care until recently. Value and performance metrics in other endeavors have achieved growing visibility, so we shouldn’t be surprised to find them crossing over into health care. Michael Lewis’s Moneyball brought these terms to popular attention for baseball in 2014, with the movie in 2011, and healthcare was bound to follow. No doubt some sense of player value governed Theo Epstein in breaking the curses of the Red Sock and Chicago Cubs with their World Series droughts of 86 and 108 years, although it’s unlikely he discovered a novel set of useful metrics.

 

 

Eight.

Value & performance. A paper in JAMA last month demands attention. Vivian Lee et al from the University of Utah offered an original investigation with the lengthy title “Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.” [JAMA 2016; 316(10): 1061-1072] A matching opinion piece in the same issue by Michael Porter and Thomas Lee offered glowing support: “From volume to value in health care”. [JAMA 2016; 316 (10): 1047-1048] While it is clear that value and performance measures will be tools to replace the American fee-for-service paradigm, the details in the Utah study are important, in particular the idea of an “opportunity index” that allows healthcare teams to understand their costs and develop lean processes that improve not just costs, but also quality, safety, and that once-vague attribute value. If leading health care centers believe in a world of value-based healthcare, such a world surely can be created. That world, however, will largely be built on the special skills of specialties and the complex teams of future medicine, wherein urologists with their singular skill sets that will likely always be prized.

 

 

Nine.

Stainless steel, eggs, & sperm. Innovation is a fundamental characteristic of biology, and randomness is always in play. At the cellular level we see innovation from the random errors of genetic transcription and the utilitarian retention of the changes in these DNA sequences when they provide a particular advantage, so one could argue that random chance lies behind all things that happen. Choice, however, somehow slips into play with life. Even low levels of cellular organization make choices and, by extension purposefully innovate in their lives. Nematodes (round worms) and flatworms, such as C. elegans and planaria, seek comfort and food as they move above their microcosms to discover opportunities or deterrents. Their actions are purposeful with deliberate directional choices as opposed to random Brownian motion. Each move is original in its own way, exploring new territory or retreating from threats. In the larger animal kingdom we see choice in behaviors of vertebrates, and hominids have taken choice and innovation to entirely new levels.

One hundred years ago Harry Brearley figured out a way to improve the quality and value of gun barrels. Gun performance deteriorated quickly after use because of barrel corrosion from moisture and gases after combustion, so Brearley considered variety of additives to create steel alloys with better resistance and found chromium most effective. This was already being used in the manufacture of steel for airplane engines, but one particular variant alloy had been difficult to examine microscopically because the etching processes used to prepare the samples for examination were far less effective than usual. The corrosion resistance problem for engine manufacturing proved to be a solution for gunsmiths.

Human innovation continues to advance even more remarkably. At our recent Nesbit meeting, Sherman Silber (Nesbit 1973) presented innovative work in reproductive medicine showing how pluripotent stem cells derived from skin cells can create eggs and sperm with full reproductive potential in normal mice.

 

 

Ten.              

jiffy-silos

Silos. Silos are disparaged glibly in modern organizational discourse, but we owe them better appreciation. Some silos are storage vaults for coal, cement, or salt while others are biologic factories. Grain elevators, for example, store and ferment grain to produce silage for animal feed. Early farmers figured this out, probably noticing it by accident. After harvesting, clover, alfalfa, oats, rye, maize, or ordinary grasses are compressed in a closed space and after a brief aerobic phase, when trapped oxygen is consumed, anaerobic fermentation by desirable lactic acid bacteria begins to convert sugars to acids. Volatile fatty acids (acetic, lactic, butyric) are natural preservatives, lowering pH and creating a hostile environment for competing bacteria. Some microorganisms in the process produce vitamins such as folic acid or B12. Ever since the early days of farming indigenous microorganisms conducted successful fermentation, although modern farms utilize select strains of lactic acid bacteria or other microorganisms more efficiently. Because fermentation produces products that bacteria consume silage has less caloric content than the original forage, but the tradeoff is worthwhile due to the preservation and improved digestibility.

Thinking about silos, it seemed natural to take a trip to Chelsea, Michigan where the family-operated Chelsea Milling Company has been making baking mixes since 1930. Mabel White Holmes created the first prepared baking mix in the United States and her grandson, Howdy Holmes, presently runs this company of 300 employees producing 1.6 million boxes of products daily. Mabel White Holmes originally marketed her biscuit mix as “so easy even a man could do it” and Jiffy Mix with its memorable blue logo became one of America’s classic brands. Chelsea Milling makes and markets 19 mixes distributed to all 50 states and 32 countries. The Jiffy Mix corporate philosophy is employee-centric, much like Zingerman’s Community of Businesses and (we believe) the Department of Urology at the University of Michigan in the recognition of how silos build a community. The Jiffy Mix silos provide dry storage for wheat, while the people that work at the company provide the fermentation that makes and innovates superior products within a lean culture of thoughtful communication and collaborative decision-making. This is biologic castling.

wh-balcony

[Next occupant?]

Whether for storage of salt or biofactories for silage, silos are ultimately useful only when working together as parts of farms and communities. This an analogy holds true in the political arena, where consensus is as important as victory. Our national and international communities suffer from self-righteous siloism. Current political rhetoric lacks dignity and respect to the point of ugliness, although the most corrosive disrespect is the a priori claim that the American political system is rigged, whether by one party, the media, or another nation. It is nonsense to be outraged that other countries are into our emails and elections – that’s exactly what we do as a nation and indeed it is the business of large nations to gather intelligence on competitors and get a thumb on the scales when possible. If our candidates say foolish things and our firewalls are weak then we should own the blame. With 4 days to our next national elections, this incivility of discourse is a short slippery slope to civil instability, which will not be good for anyone. The effect on healthcare will consequential and international scientific media as influential as The Lancet have taken the unprecedented step of hosting a US Election 2016 website: www.thelancet.com/USElection2016.  Aside from parochial concerns such as healthcare, ultimately what will matter most for all of us on the planet after November 8 will be financial market and geopolitical stability – all other concerns pale in comparison.

leaves

[October driveway]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts October 7, 2016

DAB What’s New Oct 7, 2016

 

Education, errors, & box scores

3931 words

giants-vs-cardinals

One.               Autumn is academic medicine’s high season.  With summer officially over the serious work is well underway for faculty promotions, graduate medical education (GME) in academic centers, and continuing medical education in professional meetings. Residency interviews are beginning. Coincidentally, this is also the definitive season for baseball as major league teams compete for its World Series. [Above: San Francisco Giants 6 – St. Louis Cardinals 2. Sept 15, 2016. Cueto pitching.]

With participants notching up their games, rookie mistakes become occasional, although errors never totally go away.  Performance measurements allow individuals to understand and improve their work, while inviting inevitable comparisons. Fielders in baseball, for example, are judged by errors: the number of times they fail to complete plays that could have been made by common effort, a term roughly equivalent to the reasonable and standard practice by which physicians are judged.

640px-jetererror

[Derek Jeter, Yankee shortstop. 8/24/08. Photographer Keith Allison]

It may seem awkward for physicians to talk of mistakes, however these conversations are not only necessary, but also healthy when done properly. We formalize these conversations in morbidity and mortality (M&M) conferences. Fortunately, most errors are minor if not trivial and are intrinsic to all biologic behaviors, indeed species variation itself is built on error. Health care cannot be expected to be exempt from error, for who among us has not missed a blood draw or an IV placement on first puncture? Who has not made a transcription error when typing an entry into today’s electronic medical record systems. (When I trained to become a surgeon, typing skills were not a required skill set; today many surgeons spend nearly as much time typing as operating – surely an epic waste of health care resources.) On the other hand, serious complications such as postoperative bleeding, deep venous thromboses, anastomotic leaks, or missed relevant comorbidities, bear inspections that should inspire personal and systemic improvements to minimize errors for future patients. While we take errors very seriously, we can’t let them disable us, for the next patient is always in line.

The point to make is that the conversation of error in health care is essential. The practice of medicine is, indeed, a practice and things that don’t turn out as intended need to be investigated to improve quality of practice. Charles Bosk’s 1979 book, Forgive and Remember, is a classic starting point. You can get a good summary of it in Robin Williamson’s review of its 2003 edition [J. Royal Society of Medicine. 2004 Mar; 97(3): 147-148]. While surgical fields have a long history of tough treatment of trainees, surgical training today (GME) is far less recriminating when errors are the result of earnest effort. [Below: Ed McGuire lecturing as emeritus professor to residents last year.]

mcguire-lecture

Two.           An astonishing array of events emblematic of our three-way mission initiated the 2016 academic high season of urology in Ann Arbor.

Inspiring Discovery was a celebration at North Campus Research Center focusing on partnerships with donors that fuel education and research. Tom Varbedian, distinguished Michigan alumnus, friend of our department, and retired ophthalmologist was among those honored, in his instance for support of medical students. He has funded 14 students over the years and 4 “Varbedian scholars” are presently here in medical school. [Below: Tom and some of his students]

varbedian-students

The evening was rich in meaningful stories of partnerships between donors and faculty to grow the conceptual basis and technology of health care while educating the next generation. Endowments are the key strength of Michigan’s future as a great academic medical center.

Dow Division Health Services Research Symposium targeted the topic of performance. The program by Jim Dupree, Khurshid Ghani, and Chad Ellimoottil featured our own and other world-wide experts who investigate and innovate health care delivery. This third biennial meeting included around 200 attendees.

screen-shot-2016-09-24-at-4-08-20-pm

Jerry Weisbach Lectureship last month brought Martin Gleave from Vancouver, BC to discuss his extraordinary work co-targeting the androgen receptor and adaptive survival pathways in advanced prostate cancer.

Nesbit alumni weekend featured Freddie Hamdy from Oxford University describing his unique randomized trial of active monitoring, radical prostatectomy, and radiotherapy for localized prostate cancer. Two NEJM papers from his group last month attracted international attention and Freddie’s talk to us was the first public presentation. At the cutting edge of reproductive medicine, Sherman Silber explained how the Y-chromosome is becoming redundant in the light of the incredible accomplishment of creating sperm and ova from skin fibroblasts. Many other talks filled the program. We were honored to have senior urologists Cheng-Yang Chang, Clair Cox, and Mark McQuiggan in the audience. Cheryl Lee (Chair at OSU) and Stu Wolf (Associate Dean at Austin’s Dell SOM) were honored at our alumni dinner and John Park won the John Konnak award for service to our department. A lively Nesbit tailgate party preceded the Wisconsin football game.

hamdy

[Above: Freddie Hamdy presents results of prostate cancer trial. Below: Freddie Hamdy, Marschall Runge, Sherman Silber, Jim Monte & Nesbit attendees]

nesbit-group

After the Nesbit tailgate we saw Michigan edge Wisconsin out 14-7. Next year’s Nesbit alumni reunion will align with the Air Force Academy game here in Ann Arbor.

coxs-wisc-game

[Clair & Clarice Cox tailgating]

The Montie Visiting Professor was Ian Thompson, Jr.,  Director of the Cancer Therapy & Research Center of the University of Texas in San Antonio. Ian (below) spent childhood years (1956-59) in Ann Arbor when his father was on the Michigan urology faculty. A West Point graduate, Ian became Colonel in the U.S. Army and chair of urology at University of Texas San Antonio. He is President of the American Board of Urology. He spoke to us on the future of prostate cancer detection and therapy, and heard superb presentations from our residents and fellows.

montie-thompson

[Ian Thompson, Jim Montie]

This past month has been rich in education. Although these costly events interrupt the clinical work that supplies their main funding, they are educationally essential and important for quality improvement and team alignment. Quality of care is improved by expanding the conceptual basis of medical practice, clinical skills and professionalism of the workforce, and delivery systems. Alignment of healthcare workers is critical to their success in teams. In the face of new technology, new diseases, and a changing socio-economic-political environment these educational efforts cannot be sacrificed to clinical throughput.

Three.           The attendant at the gas station of life was a picturesque metaphor of Dr. Horace Davenport as he taught first year physiology to medical students here in Ann Arbor in the later 20th century (re-quoted by us in July What’s New and Matula Thoughts). The actuality of a physician’s role is more complex, as Dr. Davenport well knew, and the irony of his specific term attendant in the midst of an academic medical center full of attendings was probably intentional. (Another irony is that today’s gas stations, in contrast to those of Davenport’s time, are mostly self-service).

A physician is better understood from the neuroscience perspective with respect to mirror neurons. Humans are not unique in having these sophisticated forms of quorum sensors that facilitate empathy, a phenomenon seen in certain other biologic species such as crows, elephants, and of course fellow primates. Humans, however, have tools, skills, and systems that allow highly developed ways to operationalize empathy.

Physicians can no longer speak so territorially about their roles because health care is provided as significantly by nurses, physician assistants, and other advanced practice providers (APPs). The awkward term health care provider has crept into general use, and while downplaying the physician as a professional, the new terminology is necessary in the team play of modern healthcare. Regulatory and corporate forces reduce health care services to commodity encounters that match diagnostic codes to treatment codes. Many encounters can be delegated to APPs working at high ends of their scopes of practice. While vaccinations, dental cleaning, and sports physicals can readily be commoditized, whether routine “well patient” check ups or visits for uncharacterized problems can be similarly commoditized in 15 to 30-minute encounters remains to be seen. Some patients need the magic of attention and intuition from a health care professional that is not readily translated to check lists or passed down the ladder of expertise.

Effective attendants at life’s service stations hone their skills to observe and listen carefully while practicing their craft. In the process of listening and observing they need not only determine a patient’s diagnosis and an attendant treatment (ICD 10 and corresponding CPT codes), but also must discover relevant issues of the context of that person’s life in terms of livelihood, family, neighborhood, or socioeconomic condition. Context amplifies or minimizes any diagnosis and therapy. Without understanding the patient’s life story, that is the ultimate co-morbidities, an actual encounter in the office may have little value to the patient. All this is to say that effective attendants (physician, medical assistant, nurse, advanced practice provider, etc.) must seek to understand the patient as fully as possible, although such understanding is illusive and always incomplete.

Four.              Rabbit holes in time.   An article earlier this year in The Lancet by Kingshuk Pal, “Could you wait a second,” described a clinic visit with a woman in her mid-thirties. The encounter was allocated for a mere 10 minutes in his National Health Service (NHS) clinic in London, and in spite of an earlier add-on patient Pal was back on time for the last patient of the morning. He assumed the visit would be a simple encounter for a prescription, and indeed things started out that way. In fact, Pal had seen the same lady in brief encounters twice before and his colleagues had seen her other times as well to write prescriptions after going through standardized template checklists. However, Pal noted:

“But things didn’t feel quite right. I interrupted my internal monologue to go back over what she had just said … There was something about the vehemence with which she had expressed herself that jarred.”

Follow-up questions led into a “rabbit hole” that revealed an unexpected terrible social situation of an abusive marriage. Pal called in appropriate support services and eventually the lady became able to take control of her life. The missed opportunities to uncover the critical social comorbidity (spousal abuse) that was the basis of all of the previous encounters with the well-intended NHS physicians surely would be considered errors in other occupations. Pal commented on earlier missed opportunities to rescue the patient:

“… each time we had stuck to our templates. We were focused on her medical needs. We had listened to what she said, but not what she meant. What had been left unsaid was how much she needed kindness, sympathy, and patience. For me to give her a few seconds of my silence so that she could finally break hers. I know if I had been busy, it would have seemed like that would take forever. But the passage of time is a peculiar thing. As strange as in a consultation as it is in Wonderland:

Alice: ‘How long is forever?’

White Rabbit: ‘Sometimes, just one second.” [The Lancet. 387:1900-1901, 2016]

Five.               Attending at the station. John Berger’s factual description of a rural English general practitioner in the 1960s is an understated gem of medical literature. Berger and photographer Jean Mohr spent six weeks with the doctor. More than shadowing him, they embedded in his practice, living with him and his wife in St. Briavels in the Forest of Dean, Gloucestershire. The physician, John Eskell, was named John Sassall for the book, A Fortunate Man: The Story of a Country Doctor, although accounts of patients and the community were otherwise factual. Berger and Mohr observed Eskell/Sassall in his clinic (called the surgery) and dispensary, as well as on his house calls.

a%20fortunate%20man-2

This somber book has underlying themes of optimism in human kindness, meaning, and extraordinary curiosity that some people, such as Eskell possess. Berger explains how the morbidity and comorbidities of patients became the personal burden of Eskell.

“I said that the price which Sassall pays for the achievement of his somewhat special position is that he has to face more nakedly than many other doctors the suffering of his patients and the sense of his own inadequacy. I want now to examine his sense of inadequacy.

There are occasions when any doctor may feel helpless: faced with a tragic incurable disease; faced with obstinacy and prejudice maintaining the very condition which has created the illness or unhappiness; faced with certain housing conditions; faced with poverty.

On most occasions Sassall is better placed than the average. He cannot cure the incurable. But because of his comparative intimacy with patients, and because the relations of a patient are also likely to be his patients, he is well-placed to challenge family obstinacy and prejudice. Likewise, because of the hegemony he enjoys within his district, his views tend to carry weight with housing committees, national assistance officers, etc. He can intercede for his patients on both a personal and bureaucratic level.”

Six.                 Personalized medicine. Comorbidities unquestionably impact illness, and without understanding them in at least some depth, physicians can hardly claim to deal out meaningful advice and therapy. Today we confuse recognition of comorbidities, by our ability to list billing codes, with actual understanding of comorbidity relevance and impact. Prominent in Sassall’s example is the matter of who he is outside the clinic and dispensary. He represents something positive in the community and accordingly he is not quite free to live a life that doesn’t impact favorably on him, his environment, or his profession. He accepted that “trade-off” when he accepted his role as a physician. Berger continues his explanation.

“He is probably more aware of making mistakes in diagnosis and treatment than most doctors. This is not because he makes more mistakes, but because he counts as mistakes what many doctors would – perhaps justifiably – call unfortunate complications. However, to balance such self-criticism he has the satisfaction of his reputation which brings him ‘difficult’ cases from far outside his own area. He suffers the doubts and enjoys the reputation of a professional idealist.

Yet his sense of inadequacy does not arise from this – although it may sometimes be prompted by an exaggerated sense of failure concerning a particular case. His sense of inadequacy is larger than the professional.

Do his patients deserve the lives they lead, or do they deserve better? Are they what they could be or are they suffering continual diminution? Do they ever have the opportunity to develop the potentialities which he has observed in them at certain moments? Are there not some who secretly wish to live in a sense that is impossible given the conditions of their actual lives? And facing this impossibility do they not then secretly wish to die?”  [Berger. A Fortunate Man. 1967. Vintage International Edition 1997. p. 132-133.]

sassall

[Jean Mohr photo p. 50]

The doctor confronts existential issues in these questions. Berger makes the case that Sassall’s biggest inadequacy was an inability to counter the comorbidities that framed the immediate morbidities of his patients. Sassall was an idealist who tried to fix morbidities and co-morbidities patient by patient. His intermittent successes fueled his perseverance.

Seven.           Mistakes. Medical practice in Eskell’s day was mainly the binary proposition of doctor and patient, family “comorbidity” notwithstanding. Physicians had far fewer tools at their disposal than today’s incredible armamentarium, but it requires teams to deploy modern healthcare’s tools. No single John Eskell can deliver today’s miracles, although confoundingly the complex paradigm of multidisciplinary team medicine greatly increases the opportunities for error. The complexity of healthcare today and the multiplicity of people involved in the teams delivering it, has magnified the chance for mistakes in the intervening half century.

The Journal of the American Medical Association recently introduced a new department, JAMA Professionalism, with an inaugural article on disclosure of medical error. The case summary described a dermatologist who had just performed skin biopsies on two patients only to discover that the instruments he had just used had not been sterilized. The ensuing discussion revolved around the issues of disclosure and analysis of the error to preclude its repetition. [W. Levinson, J. Yeung, S. Ginsburg. Disclosure of medical error. JAMA 316(7):764-765, 2016]

A phrase has stuck with me from John Shook, the insightful “zen-master” of lean processes: I can’t remember exactly where or when he said it, but it goes like this: for us to fulfill our role, we have to keep on learning. screen-shot-2016-09-11-at-8-17-58-pm

[John Shook on right with Jack Billi]

Eight.             Retrograde thoughts. Everyone brings a unique identity to their work, and in health care the idiosyncrasies of each practitioner resonate with particular specificity in the nature of his or her practice. The professional motivations, world-view, aspirations, distractions, personal demons, work-ethic, curiosity, consistency, empathy, attention to detail, ability to listen and observe, as well as commitment to community are unique to each practitioner and are manifested distinctly in each practice, and with each patient. A mandate for professionalism is intended to bind all these variables together in the practice of medicine, but this is necessarily a vague aspiration although a national trend seeks to define a professional standard and perhaps reduce it to metrics and benchmarks. A national set of professionalism standards or a GME curricular competency can never replace the role models of John Sassall/Eskell and so many others.

It may be subversive to suggest, in today’s world of measurement and precision in medicine, that if you can’t measure something of importance, you still can (and must) improve it. The discovery of what matters to a patient may not be readily measureable. On the other hand, for things that are measureable a certain degree of precision does not matter. Whether you weigh 170 pounds vs. 169.573 pounds, or whether your creatinine is 1.2 or 1.18746, or if your BP is 120/80 or 117.3/78.4 the precision is irrelevant. However, if your abdominal aortic aneurysm or renal transplant are managed by medications that you are reluctant to admit you can’t afford – that fact really matters.

Nine.              A growing body of literature punctures any remaining illusions of the perfection of medical practice. Atul Gawande’s Complications and Henry Marsh’s Do No Harm are good examples of this genre of story-telling and introspection. This type of work is instructive, although limited to single examples of individuals, sometimes approaching the point of titillation or voyeurism. Anecdotes certainly have value, acting like fables that accrue in our minds and bring us to greater wisdom in future actions. Lacking any real-time peer review and team-based process improvement, however, these personal denouements and anecdotes are unlikely to achieve larger scale in medical practice quality improvement.

Autopsy of errors or failures is more purposeful in driving deliberate changes in the ways we deploy work, whether in the structure of a clinic visit or the steps in an operative procedure. This turns out to be the very holistic idea of the Toyota Process Systems that has translated in western business as lean engineering. Reconsidering that pseudo-scientific phrase, if you can’t measure it you can’t understand or fix it – this adage is useful, but should not become dogma. Of course, measurement is essential to understanding and improving things, but measurement is not central to all sophisticated human processes. Ideas are central to understanding and progress, and measurement is only a tool used along the way to test hypotheses, measure performances, or test results.

henry_chadwick_baseball

Henry Chadwick (1824-1908) initiated the practice of recording statistics based on his experience in the game of cricket. He applied these methods to baseball after discovering the game in 1856 while “cricket reporter” for the New York Times. His box score for reporting the game, adapted from the cricket box score, has blossomed into contemporary baseball statistics of batting average, runs scored, base on balls, strike outs, runs batted in, earned run average, fielding percentage, and errors, to name a few before falling into the more complex Sabermetrics. Numbers can replicate or model a game, but they cannot substitute for the performance of the game itself.

1876boxscore

[1876 Box score: Wikipedia]

 

 

Ten.               Boston surgeon Ernest Amory Codman (1869-1940) was an intellectual successor to Chadwick in the realm of health care, where scoring is more complex than in baseball. [Below: Codman collecting data.]

codman

Eskell and Codman were obsessively committed to their work, but centered on the patient in different ways. Both men were mavericks. Codman focused on measureable outcome, he called this the end result idea, and believed that individual physicians and hospital record systems should keep relevant information. Eskell attended to the patient in the moment and in the environment. Each physician was overwhelmed by his own idea. Codman became alienated from his colleagues and went bankrupt self-publishing his book on the end-result idea, A Study in Hospital Efficiency.  Eskell focused on his immediate performance delivering health care one patient at a time, attentive to their inevitable comorbidities, but he ultimately committed suicide. Whether their unfortunate ends were due to highly sensitive mirror neurons overwhelmed by the woes of the world, or obsessive personalities that closed the door to sufficient joy to offset their burdens is a mystery.

The word detachment caught my attention when I finished surgical residency at UCLA. My inspirational chief was William P. Longmire, Jr. and, just as our completing residents and fellows and the Nesbit Society, I was given a diploma when I finished training. The Longmire Society logo was a symbol with four corners that read: Detachment, Method, Thoroughness, and Humility. At the time (it was 1977) I understood three of the attributes, but found detachment somewhat odd: why include that word?

Over the years. I’ve come to understand it better. Clearly, Codman and Eskell suffered from inadequate detachment. Dr. Longmire, a great surgeon, found the right balance. He knew his patients quite well, but had the necessary detachment to make a grand incision, put his hands in the abdomen, and fix most any problem with exquisite skill and judgment. He felt the need to warn young trainees to develop similar detachment.

The world is different today. Minimally invasive surgery, OR checklists, and electronic health records serve their purposes, but distance us from patients. Indeed, with robots a surgeon never needs to physically touch a patient, surrogates and checklists can stand in the way. Don’t get me wrong, I have benefitted from the robot and I believe in systems (although not obsessively). However, when it is not the surgeon’s hand that makes the incision and it’s not the surgeon’s hands in the body, the doctor-patient relationship is changed, even if in a subtle way. This is reminiscent of the old farmer’s adage: if you have ham and eggs for breakfast, the chicken was involved, but the pig was committed. The new tools, the regulations, scorekeeping, and the economics of health care have created an environment of significant detachment for our trainees. We no longer need to warn them to develop that sense, rather we need to inspire the right extent of involvement and commitment that will lead them into rabbit holes and other avenues of inquiry as caring attendants at the gas stations of life.

Health care performance is now judged by a multitude of variables, some worthy and others less so: patient outcomes may not be evident for years, peer review at M & M conferences drives quality improvement, and performance measures du jour, such as Press Ganey data, remind us of our public responsibility. Ultimately, our game has no final box score. The practice of medicine is an individual art, evolving as knowledge and technology accrue and as self-knowledge notches up, one hopes in lockstep with experience, patient by patient, whether in the springtime or autumn of our careers. Measurements can improve elements of our performances, but will never substitute for artful performance itself.

dsc01844

[Michigan 14 – Wisconsin 7,  Nesbit Weekend 2016]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts. September 2, 2016.

DAB What’s New Sept 2, 2016

Matula Thoughts. September 2, 2016. News & views.

3821 words

 

Sept 2016

One.   Summertime news.  Yesterday was the beginning of meteorological autumn and tomorrow is Michigan’s first football game of the season, here at home with Hawaii. Ann Arbor days were hot this summer, but are getting shorter, although not so short yet since we can travel between home and work in daylight at least in one of the directions. [Above: the drive on Huron Drive] September was the seventh month in the old Roman calendar when March served as the first month of ten in the year (see April 1st Matula Thoughts). Calendar reform added January and February to create a 12-month year and September got demoted to the ninth month, but retained its historic name.

       We had a good summer, overall, in spite of local, national, and worldwide tragedies admixt with the ongoing environmental degradation of which we are no longer innocent. Our particular geographic microcosm, however, has been mostly pleasant and constructive with the entry of new house officers, promotion of their seniors, incorporation of new fellows, and initiation of first year medical students. We enjoyed the Ann Arbor Summer Festival, Art Fairs, Chang-Duckett-Lapides lectureships, White Coat Ceremony, and lovely three-day weekends that come to an end with Labor Day on Monday. A few weeks back Mani Menon from Henry Ford Hospital gave a brilliant Grand Rounds talk on his remarkable achievement of translating radical prostatectomy to the robotic platform, and thus introducing a new paradigm of therapy worldwide (below: Mani Menon, Khurshid Ghani, Andy Brachulis). Stu Wolf had his last day a week ago and will now be doing his part to build a new medical school in Austin, Texas.

Menon

In mid-August we lost a wonderful colleague and pediatric surgeon, Dan Teitelbaum (pictured below), after a difficult struggle with brain cancer. Dan partnered with us in the Disorders of Sex Development program and was a world authority on pediatric gastrointestinal problems both clinically and in the research world. Dan was more than just a colleague, he was a kind, skilled, and reliable partner-in-care and his excellence made us better. We could always count on Dan. Brain cancer, all cancer, is an evil destroyer of the good things in life. We are making progress against cancers on many fronts, but not in time for Dan.

Dan

A road trip this summer to Toronto featured Sick Kids Hospital’s Gordon McLorie symposium for the latest news in pediatric urology. [Below: McLorie Symposium] The Olympics captured much attention during my visit north of the border and, flipping back and forth on television, it seemed that Canadian coverage favored more actual sports and news than broadcaster celebrities and opinions on American networks.

McLorie Symposium

Bruce Hornsby & The Noisemakers appeared back in Ann Arbor at the Summer Festival one evening. Many of us (of a certain age) recall the classic song, The End of the Innocence, Hornsby wrote with Don Henley in 1989. At the Power Center Hornsby and the Noisemakers expanded the piece into an amazing long version with riffs, explorations, and pleasing dissonances. I wondered if the composers intended some reference to Songs of Innocence and Experience by William Blake in 1789 and 1794, but in any case the piece struck me more meaningfully this summer than when I first heard it years ago. Jeff Daniels joined the Hornsby ensemble for an encore and performed his new composition on the iconic environmentalist Henry David Thoreau.

EO & JD

Back in 2009 Daniels and E.O. Wilson received honorary degrees from The University of Michigan (pictured above). Wilson, above on left, is our planet’s most credible spokesman for biodiversity. Recognizing this at a dinner in their honor, Daniels commented self-effacingly something like: “I really don’t know why I am here, for after all, my claim to fame is a film called Dumb and Dumber.” In fact, both honorees are substantial contributors to society and they have comfortably crossed intellectual boundaries. Daniels’ work, for example in The Newsroom, not only entertains, but also speaks to the better nature of mankind, offering an example of a trustworthy television journalist navigating the challenges of corporate broadcasting. Wilson, on the other hand, successfully ventured out from his academic world with the novel, Anthill.

Blake - innocence

[Title page: Songs of Innocence and Experience Showing the Two Contrary States of the Human Soul. 1826 edition. At Fitzwilliam Museum, Cambridge, UK]

 

 

Two.   Experience. A new season of academic medicine begins each September and renews the process of turning innocent medical school graduates into experienced urologists. Medical students cram our urology services to test out the idea of careers in urology and audition for 4 available PGY1 (intern) slots, while our residents quickly ascend their ladders of experience and our faculty hone their practices.

Consult DB

Above you see Julian Wan at Grand Rounds presenting awards to residents Duncan Morhardt, Amir Lebastchi, and Parth Shah for their achievements with consults in Julian’s innovative Tour de Consult. The next picture shows faculty and residents that same Thursday morning at 7 AM listening to talks from medical students. The newly redecorated conference room is a big improvement over its previous 1986 version, although we still run out of space.

Grand Round

Our residents, however, are enjoying ample private space in their new residents’ room we gained recently and which was significantly upgraded thanks to contributions by Jens Sönksen (Nesbit 1996) and a number of other alumni. [See picture on our matching departmental Instagram https://www.instagram.com/umichurology/, courtesy Pat Soter]

This autumn we expect 21 clinical clerks (six 4th year medical students from UM and 15 from other medical schools) to rotate with us. The individual Grand Rounds presentations they make during their stints over the course of my career at Michigan get better and better in sophistication of presentation skills and subject mastery, indicating that the next generation of urologists should surpass us. Later this autumn a subset of our faculty will personally interview about 40 other students from a pool of 350 applicants. In December we will rank all applicants just as they will rank us, a computer will do the matching and by February we will know the names of our next 4 entering residents.

Autumn will also be busy with sectional and subspecialty conferences, national meetings of the American College of Surgeons and other organizations. Abstracts will be due for next year’s big clinical congress of The American Urological Association in Boston. Family life restructures for many of our faculty when children head back to school. Also this fall a presidential election will take place, so make arrangements now so you can vote on Tuesday, November 8.  I’ve learned from sad experience that busy clinicians and staff cannot count on finding a voting window during election day unless they have made deliberate plans, like absentee ballots, far in advance. Unprepared, you may get lucky – or not.

 

 

Three.

Radio tuner 1920s

Far from the town crier and printed circular, radio was a big step in the dissemination of news. Radio itself began in 19th century, arguably with the wireless telegraphy patent of Guglielmo Marconi in 1896, but the first tuning system, patented a century ago, brought choice and accessibility to the public. Ernst Alexanderson, an engineer for General Electric in Schenectady, New York, developed the selective tuning system. Station choices grew on AM radio [Above: vintage radio tuner c. 1920s, Wikipedia] and later with FM, thanks to generous regulation and commercial competition. When I spent a year training in Great Britain as a resident in 1976-77 only 4 radio choices were available on my radio, in addition to an off-shore “pirate” station, because government tightly controlled airwaves.

1939_RCA_Television_Advertisement-1

[Radio & Television Magazine X (2): June, 1939. NY: Popular Book Corporation]

Television portended the end of radio after the first public television broadcast in 1927 and color TV in the 1960s made the medium even more irresistible. The prophecy was wrong, however, as radio rebounded with multiple new consumer channels and TV became just the newer communication layer. Radio stations provided “narrow networks” of sports talk shows, partisan political commentary channels, business news stations, religious channels, local news, weather, and some splices to television channels. Reemergence of radio’s early variety shows appeared with Garrison Keillor and the ubiquity of NPR gave radio large new audiences; the final broadcast of A Prairie Home Companion this past July 2 completed its extraordinary 42-season run. Commercial satellite radio produced an explosion of new radio species for an astonishing range of human interests from Elvis to POTUS Politics. Cable TV ended the domination of broadcasting networks, although the proliferation of new television channels added only precious few of quality.

Radio and television “news”, however maintained a sense of integrity with trusted journalist/broadcasters such as Edward R. Murrow who told it clean and straight, in contrast to advertising or propaganda. At some point, however, the term “content” subsumed “news” and clarity began to vanish. Entertainment mingled with news broadcasts and trusted news broadcasters appeared in fictional stories further blurring the border between truth and fiction.

Podcasts, cable and satellite media, and other innovations offered content to seriously compete with network television and the movie industry. Home Box Office (HBO) produced its first original movie for cable TV in 1983 (The Terry Fox Story) and other memorable films and series followed including Breaking Bad (2008-2013) and The Newsroom (2012-2014) with Jeff Daniels who should inspire a future generation of good journalists. (What Game of Thrones inspires is not so clear). Personal phones, computers, and video streaming bring yet newer layers and innovations to communication, information, and entertainment. Mini-series binge-watching eroded prime time network television while Netflix’s video streaming expanded into a new model of content production. Abandoning the pilot and sequential release of episodes, House of Cards (2013) offered an entire series for immediate consumption. The bottom line: new communication technologies add new layers rather than replacing the older media.

 

 

Four.

Alex Zazlovsky

Quorum sensing.  A few months ago at Grand Rounds Alex Zaslovsky, representing the lab of Ganesh Palapattu, gave an excellent presentation showing how platelets communicate with tumor cells to help them metastasize.

A process much like bacterial quorum sensing seems to be occurring, and perhaps this type of communication is prevalent throughout all life forms, whether gaining a consensus in a microbial biome to release endotoxin or a majority in a society for an election or an action on an issue. Strictly speaking, quorum sensing is a matter of individual gene regulation in response to news of cell population density. In other words, gene expression is coordinated according to the size and needs of the population. In the larger sense, quorum sensing allows individuals, that by themselves may be insignificant, to become superorganisms. Bacteria thus act in congress like multicellular organisms and this process works in bigger species such as social insects, fish, mammals, and likely all biologic creatures in ways we have yet to understand. This phenomenon brings us back to the seminal work of E.O. Wilson who linked ant pheromones to sociobiology and then to human consilience.

Quorum sensing is basically a matter of getting news, that is acquiring information about the environment so as to change or maintain behaviors. Weather (temperature, humidity, and pressure) is a form of news, but news about other creatures (one’s own species and different ones) also has great relevance for the immediate and intermediate future. Just as people learn individualistically, they collect news idiosyncratically. A hurricane or a full solar eclipse in mid-day gets everyone’s attention, but most news we need or crave is more discrete, while the media we employ to collect it are many and increasing in variety. Newspapers, radio, television, personal computers, and smart phones expand human quorum sensing and newsgathering far beyond the wildest expectations of Gutenberg with his printing press. New forms of social media layer upon each other and get tested in the market. Michigan Urology has its regular What’s New email, web site, Facebook page, Twitter Account, Matula Thoughts blog, and will now test out a weekly Instagram photograph that we hope will attract not only viewing interest, but also contributions from the readership.

We started putting Matula Thoughts on a web site three years ago mainly as an archive and an alternate access because our What’s New email list was getting cumbersome. While we don’t know much of our ultimate email audience, due to multiple forwarding, the matulathoughts.org web site provides visibility of readership as seen in the snapshot below of the first 6 months of 2016.

MT readership 2016

 

Five.   Thoreau away thoughts.  Coming into work one day this summer I was listening to an audio book by Chris Anderson, the head of TED Talks, and had just come to his optimistic conclusion about mankind when I stepped out of my car on the Taubman lot and was offended by a bunch of pistachio nutshells someone had dumped on the deck. My first thought was “What jerk did this?” but after reconsidering I thought Why should I care?

Pistachio

After all I was wearing shoes and those shells weren’t going to hurt my feet. They don’t harm the environment, aside from minor aesthetic degradation, and even so some modern artist might consider the pattern a compelling expression of random human graffiti. Possibly I myself had been such a jerk making similar transgressions in the past, before my sensibilities (presumably) matured. No sharp demarcation exists between the clueless citizen and the clinically certified narcissist, although most of us can tell the difference at any moment. Another label for the parking lot perpetrator springing to mind was the less complimentary anatomical term for the gastrointestinal tract terminus, a word that has an important place in organizational theory (RI Sutton, The No Asshole Rule, The Hachette Book Group, 2007). Thanks to the ubiquitous cell phone camera I was able to record this minor breech of civility for a teaching opportunity. The lesson being that the environment is our nest, but general appreciation of its limits is poor, in spite of great thinkers from Lucretius to Henry David Thoreau to E.O. Wilson who have tried to raise our sensibility.

Thoreau

Thoreau was a curious fellow, best known for his Walden Pond seclusion, possibly because he didn’t consider himself very sociable. The above daguerreotype was taken in response to a request by Calvin R. Greene, a Thoreau disciple living in Rochester, Michigan. Greene began corresponding with Thoreau in January, 1856 and asked for a photographic image, that Thoreau initially denied, saying: “You may rely on it that you have the best of me in my books, and that I am not worth seeing personally – the stuttering, blundering, clodhopper that I am.” Greene’s persistence paid off and in June of that year Thoreau sat for three daguerreotypes at 50 cents each in Worchester, MA at the Daguerrean Palace of Benjamin Maxham. Henry David must have at least liked the third image, sending it to Greene, noting: “… which my friends think is pretty good – though better looking than I.” [Image and description, National Portrait Gallery, Washington, DC]

 

 

Six.   News. It’s a nice coincidence that NEWS could be an acronym for north, east, west, and south. The reality, though, is that the English term arrived in the 14th century as a plural form of “new” information. For 14th century English village folk, relevant news included weather, gossip, crop issues, births & deaths, accidents, plague, and war. In turn over time town criers, newspapers, radio, and television carried news among villages, through cities, and across continents. A new profession arose as journalists pieced events together and investigated them to derive factual stories. Photographs and today’s video clips offer powerful encapsulations of news in images and voices. Aggregation of news and targeting it to audiences with narrow interests is not new, we saw it in People magazine, the Racing Form, and Popular Mechanics, but daily news aggregation on the internet compiles information on a global scale and devastated the business model of investigative journalism. The Newsroom attended to the tensions between regurgitated information, narrative truth, and corporate self-interest. Human quorum sensing is immeasurably more complex than that of E.coli, although the basic principles must be quite similar. The variety of ways to collect and disseminate news from quorum sensing to Instagram will continue to expand, and each of our growing number will adapt our own methods and devices to capture what we will.

Newsboys Pose c 1890 copy

[Ann Arbor newsboys c. 1890]

 

 

Seven.    Urology news & Ig Nobel Thoughts. Later this month the 2016 Annual Ig Nobel Prize Ceremony takes place at Harvard’s Sanders Theater (September 22) to introduce 10 prizewinners for accomplishments “that make people laugh then think.” We expect no winners from the ranks of UM Urology, although it is worth mentioning that one winner last year was a study of mammalian urination times that found “golden rule” wherein urination times ranged around 21 seconds regardless of the species or bladder volume. This work, published in PNAS (a curious acronymic homonym), begs further investigation to explore gender differences, age effects, and the relations to various pathologies such as BPH [Yang et al Proc Nat Acad Sci 111:11932, 2014]. Notably, the first reference in the paper was Frank Hinman, Jr.’s book On Micturition (1971). The Ig Nobelists, however, missed Hinman’s smaller limited edition book called The Art and Science of Piddling [Vespasian Press, San Francisco, 1999] Hinman (shown below) playfully censored the retromingent stream of the rhinoceros on the book cover. To what end this unusual direction of micturition has evolved remain unclear, but extinction may void the species before an explanation is discovered.

Piddling

Hinman-office copy

 

 

Eight.   Photography. If you happen by the National Archives, as we did on a brief visit to Washington this summer, you might spot the Daguerre Memorial on Ninth Street by the Department of Justice. American sculptor Jonathan Scott Hartley (born in Albany, NY 1844, deceased 1912) produced the relief bust of Louis Daguerre honored by a female figure representing fame while a garland encircles the globe in homage to the universality of photography. Harley also made busts of Nathaniel Hawthorne, Washington Irving, and Ralph Waldo Emerson, Thoreau’s friend and colleague.

Daguerr Statue

Daguerreotypes transitioned to portable film cameras and now digital images on universal camera phones that allow great visibility of the particulars of the world. Visual images are fundamental to modern communication and newsgathering. Walking near the Daguerreotype monument we noticed a discarded snuff can in a planter box similar the pistachio shell arrangement shown earlier, further evidence that the great pageant of humanity marches forward and continues to leave its mark, although now subject to universal documentation.

Skoal

A yearly photographic competition of The Lancet, called Highlights,  further opens the door to the world’s cellphones and cameras. Last year’s contest yielded 12 winners detailing: a ruined hospital in western Syria, moments of patient care, community action, a poster showing health advantages of raised beds with mosquito nets, smoking prevention, Ebola hot zone management, road traffic accidents, cleft lip repair, and the politics of social justice. [Lancet. Palmer & Mullan. Highlights 2015: pictures of health. 386:2463, 2015]

 

 

Nine.   A somber note. Last month this column concluded with reference to the Hiroshima bomb, an existential threat that has increased since 1945 by many orders of magnitude. There is little question what Henry David Thoreau, among many wise thinkers of the past and present would say on this matter of nuclear weapons: they must be contained and their spread prevented. Failing that, a doomsday scenario is not unlikely and only luck has prevented this from happening so far. A new book, My Journey to the Nuclear Brink by William Perry (US Secretary of Defense 1994 – 1997), explains our precarious situation better than anything else I’ve read. You can understand his point in a “Cliff’s Notes” fashion by going directly to Perry’s website, but his book is quite compelling and readable. Perry, currently emeritus professor at Stanford University and senior fellow at its Hoover Institution, founded the William J Perry Project in 2013(http://www.wjperryproject.org/), a non-profit organization intended to educate the public on the current dangers of nuclear weapons. Addressing close calls of the past, Perry reveals that the Cuban Missile Crisis came far closer to the brink that most people suspected, but for two unreported “mistakes” on both sides of the conflict (USA and Soviet Union) that prevented nuclear deployment. Today the risk is greater and more complex as the weapons are far more massive and numerous than 71 years ago over Hiroshima. Opportunities for accidents, terrorism, rogue nations, territorial disputes, or mistaken perceptions of “responsible” nations are too many to count.

AtomicEffects-p7a

[Above, Hiroshima before blast, above ground zero, with 1000 foot circles marked; below, after the explosion with not much left standing.]

AtomicEffects-p7b

 

 

Ten.

Cassandra

Cassandra. In Greek mythology, Cassandra was a curious prophet, who turned out to be an ineffective communicator. Attempting to seduce her, Apollo gave her the power of prophecy, but when she refused his advances he spat into her mouth with the curse that no one would believe her prophecies. Prophecy skepticism has endured since her time. Right or wrong, but forecasts require consideration, especially when backed by information, whether in the form of news or other information. [Cassandra, in front of burning Troy, by Evelyn De Morgan, 1898]

The current likelihood of a nuclear incident is great and in recognition of this an exercise called Mighty Saber was held last year by the Defense Threat Reduction Agency at Fort Belvoir, Virginia to simulate a detonation in a US city and trace the origin of the device. An article by Richard Stone in Science concluded: “… to have any chance of unraveling the details of a nuclear attack, investigators have to lay the scientific groundwork – while hoping it will never be needed.” [Stone. Science. 351:1138, 2016]

The world is full of danger and nuclear devices are but one of a number of catastrophic threats. This fact needs to be acknowledged as people go to the polls to vote for their legitimate self-interests that may involve party loyalties, economic matters, civil rights, first and second amendments, immigration, border security, health care equity, public education, government size, gender issues, free speech, law enforcement, etc. Our ultimate self-interest, however, is immediate survival of our species and the security of our children’s future. With this in mind we individually must make the best choices we can for the elections at hand. Just as importantly we, as a society, must do a far better job of leadership succession to prepare educated and wise future civil leaders rather than leaving succession up to random populists, celebrities, or narcissists who crave power and the ultimate corner offices. Geopolitical and world market stability are severely challenged and we are terribly short of good leaders and great ideas. The grim political landscape at hand, however, doesn’t give anyone of us the right to be aloof from the politics and processes of representational government.

You may ask what does all this have to do with our profession, our patients, our trainees, and our science? The answer is – everything. Our successors won’t consider us innocent if we hand over to them a diminished future in a dysfunctional society on a damaged planet. Join the important political conversations, the next generation is counting on it.

 

Thanks for reading Matula Thoughts for this first Friday of September, and on future first Fridays if you are so disposed.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor