May 3, 2019. Sensations

Matula Thoughts  May 3, 2019

Sensations

 

2180 words: twenty minutes to read, five to skim, or seconds to delete if TMI.

 

Appreciation. Leonardo da Vinci reverberates strongly, even five hundred years after his death on 2 May 1519. The Lancet commemorated yesterday’s anniversary with a cover picture of that great polymath who encompassed astonishing ideas, insights, and talents, leaving for posterity a multitude of works that amaze and delight. Anatomy, physiology, engineering, and visual art are just a few of the intellectual arenas his senses played with and his hands produced. Walt Whitman later wrote: we “contain multitudes…,” and you can fill in the words of what multitudes in particular might follow, such as atoms, cells, thoughts, physical creations, emotions, or other possibilities. da Vinci exemplified that human potential better than most of us, trying to make sense of the world.

 

One.             

Azalias 2019

Spring hits our senses. We can’t easily describe in words the perfumes of flowers or the pleasant rich scent of mulch, but we surely know them. Odors are important sensory inputs, although we don’t usually notice them much as they are less important for us than to most other creatures.  [Above: azaleas, spring 2019.]

Dogs, for example, discern far more olfactory notes than we do and that is probably a good thing, since dogs sequester significant cerebral space and energy for distinctions of specific urine scents or fecal aromas to understand who is in the neighborhood, skills that have been essential to millennia of canine culture, while humans have found other ways to evaluate their fellows and territories. [Below: Molly’s spring inspection.]

Molly

We surely would be confused by having to track of hundreds of scent variations. In fact, even a small amount of effluent odor from one of our neighbors is generally regarded as too much information. [Below: mulch delivery at Smithsonian Institution, Spring 2019.]

Mulch

Smell used to be important in medical diagnosis. Uroscopy relied on smell, color, sediment, feel, and taste of urine for clues to disease and prognosis. Historically, urine was inspected by all five senses (including the taste of urine and the sound of its stream), but now patients are told to leave a sample in the privacy of a bathroom for a medical assistant to label and send to a laboratory. Doctors rarely come close to the stuff. Even so, for any good diagnostician, a necrotic wound, uremic breath, fecal odor, or hint of tobacco, are valuable bits of information not just for a specific disease, but also relevant to the life and comorbidities of a patient. These and other points of data add to the medical gaze that transcends visual clues and once inspired the meme of clever detectives. That gaze has now been replaced by the digital gaze of checklists, smart phrases, and drop-down menus.

RueMorgueManuscript

Last month we commented on the first of the medical detectives in The Murders in the Rue Morgue, wherein Edgar Allen Poe in 1842 described how diagnostic senses could be marshaled in a process he called ratiocination to figure out crimes. The tale reflected on the odor of urine and double entendre of a name when detective Dupin explained to the narrator (Poe) how he seemed to read his mind, by making deductions from facial expressions:

“Perdidit antiquum litera sonum.

I had told you that this was in reference to Orion, formerly written Urion; and, from certain pungencies connected with this explanation, I was aware that you could not have forgotten it.”

The Latin phrase intended the loss or attrition of an old or previous meaning or sound of the word or its homonym. Orion referred to the celestial constellation (Poe called it a nebular cosmogony) and its similarity to urine became a play on words that Dupin noticed had popped into the narrator’s mind as he looked up at the constellation and smiled when the wordplay and associations came to mind. [Above: 1895 facsimile of Poe’s original manuscript for “The Murders in the Rue Morgue.” Susan Jaffe Tane collection at Cornell University. Public domain. Wikipedia.]

 

Two.

Five classic senses taught in my childhood – smell, sight, taste, hearing, and touch – have been updated to seven for my grandchildren with the addition of vestibular sense and proprioception. Technology extends the senses further, outsourcing them and merging their inputs to provide unprecedented amounts of information of the world around us and within us. Microscopy and telescopy carry sight far beyond the unaided eye, while modern imaging with CT scans, MRI, and radioisotope labeling visualize our own living interior bodies. Sound, too, allows inspection of our interiors due to the discovery of Pierre Curie and his brother in 1880 of the piezo-electric principle in crystals that underlies ultrasonography. Extending the seven “basic” senses through technology, we see the world in new ways, although at the cost of diminished acuity of our original senses.

Today’s versions of the medical gaze and the detective’s ratiocination, are powerful: the sum-total of sensory inputs (enhanced by technology) and mental heuristics of scientific thinking.  Intellect integrates the physical senses. This larger sense, the sense of making sense of everything, is the wisdom, judgment, and mental capacity that creates meaning from immediate or recalled sensory input. This may be the most important and defining human sense, but even that is challenged by impending extension or replacement with so-called artificial intelligence.

 

Three.

Ghost_In_The_Machine_cover 

Incidental or relevant? Recently, I was asked to comment on a paper regarding incidental findings of renal cysts in children and that got me thinking how far ultrasonography has come in my career. Genitourinary imaging by ultrasonography came of age as a practical urologic tool in the 1980’s. I recall those early days when, at Walter Reed Army Medical Center, we experimented with crude B-mode ultrasonography to interrogate testes for tumors or viability. Coincidentally, it was around that time, 1981 to be specific, when Gordon Sumner wrote the lyrics to a song called Too much information (TMI):

“Too much information running through my brain,

Too much information driving me insane…”

The world is even more replete with information since Sting and The Police recorded that song in their album Ghost in the Machine. Yet, one might argue that TMI is a sophomoric complaint, as if the infinite information in the cosmos should be curated for our personal capacity of the moment. The actual problem is not too much information, but too little human capacity for processing and our technologies have made this situation worse.

Kandel

Perhaps this is the essence of abstract art, that Eric Kandel expressed in Reductionism in Art and Brain Science, explaining that functional MRI shows human brains process representational art differently and in different cerebral pathways than processing abstract art (Columbia Press, 2016).  Representational art gives viewers very specific images that relate to things immediately understandable. (Below: American Gothic by Grant Wood (1930), courtesy Art Institute of Chicago.)

 

“Abstract art” seems to contain less information (perhaps less craft – or even no craft, at first glance) than representational works. Kandel finds that abstractions can in fact contain far more, calling on you to search everything you know to understand the piece. Abstract artworks invite you to inspect the world to discover their meaning, although a particular artist may not necessarily know or understand the world any better than you. The artist, however, creates a door for you to imagine the world differently than you did a moment before viewing the work. Abstract images may open up, in an informational sense, far more than a given representational scene or a moment you will readily comprehend. Abstraction is a window into far larger and stranger worlds of information, associations, and imaginations. (Below: Composition No. 10. 1939-1942, (Piet Mondrian. Private Collection. Wikipedia.)

Piet_Mondriaan,_1939-1942_-_Composition_10

edu-meet-me-volunteers

[Above: UM Silver Club members attend Meet Me at UMMA program at the University of Michigan Museum of Art. Image courtesy of UM Silver Club. The untitled painting is by Mark Bradford, 2005.]

 

Four.

The Shannon number, named for UM graduate Claude Shannon (1916-2001), represents a lower bound of the game-tree complexity of chess, 10120.  This is an enormous number, unimaginably large, given that the number of atoms in the observable universe is estimated at 1080. The point here is that human imagination (and in this instance, for only one human game), in a measurable sense, is far larger than the real world. Walt Whitman (1819-1892) may not have known the celestial math, but he wasn’t exaggerating when he wrote Song of Myself.

“Do I contradict myself?

Very well then I contradict myself,

(I am large, I contain multitudes.)”

[Whitman W. Song of Myself. Section 51, 1892 version.]

Whitman imagined that he and each of us is unimaginably large, in imagination. This is sensory overload at its most. It is ironically, unimaginable, far beyond TMI.

Whether an incidentaloma discovered by ultrasonography, computer-assisted tomography, or magnetic resonance imaging, is important to the well-being of a person or is too much information (TMI) is one of the dilemmas of modern medicine. The quality and precision of ultrasound interrogation, reveal increasingly tiny anatomic details, anomalies, and imperfections that may cause great anxiety for patients, regularly driving parents of children with simple renal cysts to near-insanity with unnecessary worry. While technology seemed to promise humans better control of their lives, it may be just the opposite, whereby technology becomes the ruling agent. [Below: the promise of technology, Life Magazine, September 10, 1965.]

life_c2

 

Five.

An article and a book expand these considerations of gaze, ratiocination, and information. Roger Kneebone, in The Lancet, offered perspectives on “Looking and Seeing,” comparing a physician’s observational skills to those of an experienced entomologist, Erica McAlister at the Natural History Museum in London. The article begins with these resonating sentences, quoted with his permission:

“Medicine depends upon observation. Yet we are changing the way we look and that alters what we see. As a medical student, I was schooled according to a rigid mantra. Inspection, palpation, percussion, auscultation – always in that order … The aim, I think, was to ensure that we directed our attention to the person in front of us, that we didn’t jump to conclusions before assembling all the information we needed. That fell by the wayside as we turned into junior doctors. Nobody seemed interested in what we had seen or how we described it. Instead, it was all about blood tests, x-rays, scans – all about results.” [Kneebone R. “Looking and seeing.” The Lancet. 393:1091, 2019.]

Kneebone says it beautifully. The last word in his phrase could easily be data as well as results. The results becomes a proxy for the patient. The physicians of the next generation have learned excellent key-board skills, data collection, acronyms du jour, and navigation of electronic health records with drop-down menus, check-lists, and cut-and-paste artistry. The artful skills taught to me and Kneebone – inspection, palpation, percussion, and auscultation – seem rendered obsolete by data. One worries if the talents to navigate technology and its data come at the expense of the medical gaze, the medical sniff, and the ratiocination Edgar Allen Poe and Arthur Conan Doyle brought forth in their detectives. The model of the astute clinician is giving way to Watson, not Conan Doyle’s Watson, but IBM’s Watson.

Information or data, if you prefer, is a false deity. We may use data but should not worship it. Too many leaders say “show me the data,” believing that data will perfectly direct essential actions. Data should inform key decisions, of course, but data needs human wisdom for good decisions – using, tweaking, discarding, or reformulating data for human needs, not for the self-serving “needs” of algorithms. Self-learning algorithms can accomplish much, but can never replace human wisdom.

The book of relevance is Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, by Eric Topol, reviewed by Indra Joshi in The Lancet and I look forward to seeing if it convinces me in its promise. [Joshi I. “Waiting for Deep Medicine.” The Lancet. 393:1193-1194, 2019.]  The concern with “artificial intelligence” is its easy confusion with human wisdom, the wisdom of crowds that tends to bend toward truth and overarching human values. Self-learning algorithms that constitute AI are ultimately constructed by individuals with their own values, biases, and agendas. Furthermore, they are susceptible to intrusion and perversion. Finlayson et al warned of this recently: Adversarial attacks on medical machine learning, emerging vulnerabilities demand new conversations. [Finlayson SG, et al. Science. 363:1287–1289, 2019.]

 

Short story.

Truth is often stranger than fiction. Poe’s story in 1841 revealed the perpetrator of The Murders in the Rue Morgue was an orangutan smuggled to Paris by a sailor. The actual murders were unintentional, the escaped animal was frightened and responding as its genes, millions of years of environmental selection, prescribed. Most readers probably found that part of the story a bit outrageous, it didn’t quite make sense that a sailor could or would smuggle such an animal. But truth is often as strange or stranger than fiction: a recent report from the Associated Press of Russian tourist Andrei Zhestkov, discovered on the Indonesian resort island of Bali trying to smuggle a 2-year old drugged orangutan in a rattan basket to Russia on March 22. The smuggler also had seven live lizards in a suitcase. [Mike Ives. New York Times, March 25, 2019.]

Orangutan

 

Thanks for reading Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Spring

Matula Thoughts April 5, 2019

Calendar1

Spring considerations

20 minutes to read, two minutes to scan, one second to delete.

2341 words

Note of Passage

Mark C. McQuiggan, University of Michigan triple graduate, passed away last month leaving his beloved wife Carolyn (Brunk). Mark was the son of the late Dr. Mark R. McQuiggan and Dr. Catherine (Corbeille) McQuiggan, internists who had trained at the Mayo Clinic and worked together in an office in Detroit’s Fisher Building. Mark C. was born on May 15, 1933 and was 85 years old at the time of his death. He was thoroughly a Michigan Man with a BS from LS&A in 1954, an MD in 1958, and urology residency under Reed Nesbit, completed in 1964. Mark’s co-residents were Karl Schroeder and Dick Bourne, and other particular friends from residency were Clair and Clarice Cox and Dick and Jane Dorr.  Mark practiced urology with excellence and devotion in Southfield, Michigan, on the staff of North Detroit General Hospital and Ascension Providence Hospital. Mark and Carolyn were lovely and loyal presences at our yearly Nesbit Society Alumni Reunions. (Below: Mark in October, 2010, at the Nesbit Scientific Session.) Mark loved the University of Michigan, and Michigan Urology, along with Michigan athletics. Michigan Urology will miss Mark, who seemed to always have a smile and was a wonderful link to Michigan Urology’s past.

Urology at Michigan undergoes its own passage, this being the transition to Ganesh Palapattu as chair, who is already bringing exciting and substantive change to the department just around the fortuitous time of the Michigan Urology Centennial. He is continuing the weekly Urology What’s New aimed at departmental specifics along with this monthly set of Matula Thoughts on the first Fridays, and simultaneously available on the web site matulathoughts.org.

 

One. 

April brings spring, so welcome after a rough winter’s polar vortices reached down to our geography and innermost bodily cores. Flowering dogwoods, photographed last year (above), will return soon and that’s much of the attraction of photography – preservation of meaningful moments with fidelity to the momentary truth. We want to hold on to things we value as best we can and photography allows us to keep them, in a way, by replication. Words can also replicate those moments and truths with fidelity and beauty.

Last spring this column referred to Dr. William Carlos Williams and his book, Spring and All, a title mysterious in its promise. [Above: Williams and Ezra Pound at their last meeting, photographed by Richard Avedon in July 1958, Wikipedia.] The central piece in Williams’ collection, On the Road to the Contagious Hospital, speaks to facilities that that have faded away, the leprosaria, tuberculosis sanitaria, and other such places. New diseases and antibiotic-resistant resurgence of the old ones may resurrect those institutions. Leprosy, by the way, is not a disease of the past. The Lancet recently had a photoessay “Picturing health new face of leprosy.” The authors noted: “… leprosy impairs and society disables.”  [Kumar A, Lambert S, Lockwood DNJ. The Lancet, 393:629-638, 2019.]

The University of Michigan once had its own contagious hospital after the citizens in Ann Arbor in 1914 voted for a bond issue of $25,000 for an isolation hospital to be maintained by the university. [Below: UM Contagious Disease Hospital, courtesy Bentley Library.] It was placed on a ridge behind the Catherine Street Hospital and looked over the Huron River. Horace Davenport’s book (Not Just Any Medical School, 1999) tells how in the first year the 24-bed hospital housed patients with chicken pox, diphtheria, necrotizing ulcerative gingivitis (Vincent’s angina), pneumonia, tuberculosis (TB), and whooping cough. [Davenport HW. Not Just Any Medical School. University of Michigan Press. 1999.]

 

Two.

Photography, as a neologism meaning drawing by light, may have had a number of separate origins between 1834 and 1839. Previous methods to capture images by means of cameras obscura or shadow images on silver nitrate-treated papers were novelties, but didn’t scale up in terms of utility, until Louis Daguerre announced his sensational process on January 7, 1839. The rest is the history of the Kodak moment, motion pictures, Polaroids, and now the cell phone camera with its albums of thousands of pictures and videos.

Anesthesia, in contrast to photography, had a specific origin in time, place, and originator. Anesthesia was the neologism of Oliver Wendell Holmes in Boston, 1846. Just as photography was coming of age, medical practitioners were starting to bring science and new technology to their art. Large metropolitan hospitals, notably the Napoleonic legacies in France, afforded large numbers of patients that inquisitive physicians studied and compared. Evolving tools of measurement and investigation allowed new clinical skills and a slowly growing sense of hygiene would bring a greater level of safety to medical care.

Professor Charles-Alexandre Louis (1787-1872) in Paris at the Pitié-Salpêtrière was among the best of these physicians and his comparison of patients with pulmonary TB who were treated with leeches against those untreated patients was one of the earliest clinical trials. Young people from around the world came to Paris for weeks, months, or years to watch Louis at work. He stressed the idea of critical clinical observation (including the medical gaze), measurement, and analysis to improve understanding of disease and therapy, forming a Society of Clinical Observation that many young American trainees joined.

The idea of clinical material as the milieu for medical education and the improvement of health care through careful observation, inquiry, and research, received as great a boost from Louis as anyone. The medical gaze went beyond a quick visual glance. Deep inspection by an experienced physician was something new, a gaze that would discover clues to a diagnosis, understanding of co-morbidities, and other relevant facts to the case, the story, and the truth of a clinical situation.

The medical gaze, like the photograph, was novel and they complemented each other. Photography became a teaching and documentary tool. The informed gaze discovered a condition, an attitude, or a moment that the photograph could replicate and preserve. The medical gaze also inspired a new genre in literature – bringing the idea of astute medical discovery by observation, listening, and reasoning to crime solving.

One wonders if the medical gaze, once a desirable clinical skill, has now been eliminated by modern imaging tests, laboratory studies, biomarkers, and check lists? This begs the question whether or not tomorrow’s masters of those technologies and processes will quickly succumb to nonhuman purveyors of “artificial intelligence”?

 

Three.

The Murders in the Rue Morgue, Edgar Allen Poe’s famous short story in 1841, initiated a new genre of crime literature and the clever reasoning, Poe called “ratiocination,” necessary to solve crimes. [Poe 1809-1849, above] Curiously, Poe’s story included a brief speculation on uroscopic clues, specifically the odor of urine.

This scientific crime solver genre continues to gather cultural momentum. The picture above, made in the last year of Poe’s life, is the “Annie” daguerreotype, the best known of the eight known Poe daguerreotypes and named for Mrs. Annie Richmond of Lowell, Massachusetts who commissioned and owned the picture. Poe was just a little ahead of his time with ratiocination, his take on the medical gaze, where careful observation and trained reasoning could discover the truth of a situation. Over the next decades up to the fin de siècle a scientific corpus of knowledge, bringing new technology, would expand the medical gaze into a powerful capacity to produce data and evidence for both health care and criminal investigation.

Future detective author Arthur Conan Doyle (1859-1930) was barely ten years old when Preston B. Rose started teaching Ann Arbor medical students urinalysis and scientific methods of forensic investigation in the Chemical Laboratory just behind the University of Michigan Medical School. Only 17 years later, as a 27-year old ophthalmologist with a struggling practice, Conan Doyle created a powerful blend of ratiocination and scientific analysis in the intellectual superhero, Sherlock Holmes. The detective was modeled on a real-life medical role-model of Doyle when he was a medical student and the name Doyle selected coincided with the real-life medical superhero Oliver Wendell Holmes, one of the most prominent Americans Abroad, who studied with Louis in Paris, as explained in David McCullough’s book. After return to Boston, Holmes presented one of the first convincing hypotheses for the germ theory to explain puerperal fever. [Below: Sir Arthur Ignatius Conan Doyle by English photographer Herbert Rose Barraud. Carbon print on card mount. Courtesy of the National Portrait Gallery, London.]

Doyle SS

 

Four.

Holmes embraced the new technology of photography, writing essays about it, making his own pictures, inventing a stereoscopic camera, and studying human ambulation with it. In the June issue of The Atlantic Magazine in 1859 Holmes commented on the improbability of the technology of capturing an actual moment in time totally on a single surface:

“This is just what the Daguerreotype has done. It has fixed the most fleeting of our illusions, that which the apostle and the philosopher and the poet have alike used as the type of instability and unreality. The photograph has completed the triumph, by making a sheet of paper reflect images like a mirror and hold them as a picture.”

It is a universal truth that pictures tell stories more immediately than words, and we humans have been practicing this art since cave-dwelling days, inspired by beauty in the natural world, fantasies, or unnatural horrors. Photography offers realistic images of faces, scenes, or situations, and complements the older visual arts of drawing or painting.

Earlier, in the inaugural Atlantic Monthly (above) Holmes had written:

“The next European war will send us stereographs of battles. It is asserted that a bursting shell can be photographed… We are looking into stereoscopes as pretty toys, and wondering over the photograph as a charming novelty; but before another generation has passed away, it will be recognized that a new epoch in the history of human progress dates from the time when He who

Never but in uncreated light

Dwelt from eternity –

Took a pencil of fire from the hand of the ‘angel standing in the sun,’ and placed it in the hands of a mortal.”

[“The stereoscope and the stereograph,” Atlantic Monthly, November, 1857.]

 

Five.

Guernica. Pablo Picasso (1881-1973) while living in Paris was commissioned by the Spanish Republican Government to make a work in response to the destruction of Guernica. This  Basque town in northern Spain was bombed for two hours by Nazi Germany and Italian warplanes in their support of Spanish nationalists on 26 April 1937. [Above: Picasso working on the mural. Wikipedia.] The town was at a major crossroad 10 kilometers from the front lines between the Republican retreat and Nationalist advance to Bilbao. The target was a minor factory for war materials outside of town. The bombers missed the factory, but destroyed the town.

Picasso completed the large oil painting on canvas in June, 1937, after 35 days of work. The specific disputes of the Republicans and Nationalists, and the justifications of their supporters and suppliers are nowhere evident in the mural, only the grotesque mangled forms and anguished expressions of the victims. Guernica may be Picasso’s greatest work and one of mankind’s iconic images of the horror of war. The event itself was miniscule in the grand scale of 20th century conflict, but Picasso made it a transcendent moment for humanity.

No single painting, photograph, or narrative can capture the full and terrible story of Guernica, although together they give a fuller sense of the horror than any one work alone. [Above: Museo Reina Sofia, Madrid, Spain. ©Picasso. Below: ruined Guernica. German Federal Archives.]

Guernica, Ruinen

Picasso had commissioned three full-size tapestry reproductions of the work by Jacqueline de la Baume Durrbach and her husband René in 1955, weavers in Southern France. Nelson Rockefeller purchased one of these and it hangs on loan in the United Nations at the entrance to the Security Council room. A blue curtain strategically covered Guernica for televised press conferences of Colin Powell and John Negroponte on 5 February 2003. [Kennedy M. “Picasso tapestry of Guernica heads to UK.” London: The Guardian, 26 January 2009.] Picasso entrusted Guernica to the Museum of Modern Art in New York, pending re-establishment of liberty and democracy in Spain. After Spain became a democratic constitutional monarchy in 1978 the painting was ceded to Spain in 1981, although not without dissent that the ruling system was still not quite the republic stipulated by the artist in his will.

 

Short bits.

Morbidity and Mortality (M&M) conferences, discussed here last month, brought M&M candy to mind. The story goes that the Spanish Civil War inspired Forrest Mars, Sr. to create an American version of the British confection Smarties. Mars was working in England in the candy business at that time, estranged from his father, Frank Mars of Mars candy fame. Forrest had created the Mars Bar in Slough in 1932 and was looking for another product. Rowntree’s of York, maker of Chocolate Beans since 1882, had recently tweaked the name to Milk Chocolate Beans in 1937, and changed it to Smarties the following year. These oblate spheroids were sold in cylindrical cardboard tubes, with a colorful lid that contained a random alphabet letter, designed to encourage children to learn. The chocolate center was protected by a shell of hardened sugar syrup to prevent melting, a convenience enjoyed by soldiers in the Spanish Civil War.

The Spanish Civil War (17 July 1936 – 1 April 1939) engendered strong international sympathies, involving anarchists, communists, nationalists, aristocratic groups, and religious factions, although largely became viewed as a contest between democracy and fascism. British volunteers, likely including George Orwell, carried Milk Chocolate Beans and Smarties into battles and Forrest Mars might have noticed. Just as likely one of his children brought some home.

Returning to the U.S. and working with Bruce Murrie, son of Hershey Chocolate’s president, Mars developed their button-shaped variant, patented it on 3 March 1941, and began manufacture that year in New Jersey. M&M derived from Mars and Murrie, with a small “m” stamped on each button. The first big customer was the U.S. Army and during WWII M&Ms were sold exclusively to the military. “Melts in your mouth, not in your hand,” was first used as a tagline in 1949. Peanut M&Ms were introduced in 1954, and the rest is history.

Thanks for reading Matula Thoughts

David A. Bloom, M.D.

University of Michigan, Department of Urology, Ann Arbor

 

 

Matula Thoughts March 1, 2019

 

DAB What’s New Mar 1, 2019

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Stories

1999 words

[Above: childbirth fever pamphlet 1855 – a fatal complication. Below: M&M complications conference at UM Urology.]

One.             

M&Ms.  Once a month our department gathers at 7 AM on a Thursday morning for Morbidity and Mortality (M&M) conference, as is typical of most surgical training programs. This recurring touchpoint integrates the triple mission of medical academia so we can learn from the serious complications inherent to our work, improve the quality of that work, and discover new avenues of investigation. Typically, residents or fellows tell a story of a complication or a death, faculty members involved consider “what might have been done differently,” others share their experiences and thoughts, and sometimes a literature-based short presentation is offered. Complications are classified by the Clavien system. [Above: January 2019 M&M with Priyanka Gupta discussing the new complications entry system.] These conferences fine-tune our mutual relevance, allowing regular inspection of our complications, discussion from the perspective of quality improvement, and calibration of individual work with that of colleagues.

When I was a resident, grand rounds centered around the chair, whose every opinion mattered. Performances as residents could make or break progression through residency and chances for fellowships or good jobs. The chair critiqued everyone else and molded the department in his image (always a “his” during my training), much like an Autocrat at the Breakfast-Table, the title of essays by Oliver Wendell Holmes in 1858. Those of us who made it through the process naturally carried a deep respect and even fondness for the chair, while others were not quite so enamored. Things have changed, especially in big departments, with decentralization to divisions and teams much more the order of the day, and while structure is still necessarily hierarchical (the buck must stop somewhere), a more democratic flavor rules the day at M&M conferences and grand rounds.

Although chairs are no longer the center of departmental universes, they set much of the tone and represent the team administratively to the rest of the institution. Departments improve when leadership rotates carefully, as it has in our case, and today it’s official: we welcome Ganesh Palapattu to our chair position, and Brent Hollenbeck as vice chair of the University of Michigan Department of Urology.

 

Two.

The Clavien-Dindo system, described in 2004 by Zurich surgeons Pierre Clavien and Daniel Dindo, assigns grades to surgical complications: Grade I events are small deviations from normal expected operative or postoperative courses; Grade II events are atypical medication needs, including blood transfusion and total parenteral nutrition; Grade III are complications requiring surgical, endoscopic, or radiologic intervention – with or without anesthesia; Grade IV are life-threatening complications; and Grade V is death. [PA Clavien et al. Ann Surg. 250:187-196, 2009.] Our M & M conferences focus on Clavien III or greater complications, mainly to identify learning opportunities: what could we do better, personally, or in our teams and systems? Human activities are inevitably susceptible to periodic errors and negative outcomes, but medical complications are serious disappointments and sometimes tragedies for patients and their families. Each complication is a story, often a complex one. Faculty and residents must learn from them, grieve over them, and learn to deal with the adversity. Just as importantly, surgeons must move on to take care of the next patient. The seminal book Forgive and Remember by Bosk, discussed on these pages in the past, is worth renewed attention. [Bosk CL. Forgive and Remember. Managing Medical Failure. University of Chicago Press. 1979.]

Getting “the story” right is a universal necessity, whether from personal points of view, social perspectives, or occupational demands. Journalists, teachers, politicians, engineers, lawyers, and physicians need to understand stories and ascertain truth. Surgeons need to know a patient’s story from the diagnostic perspective in order to come to operative solutions, and if complications occur, then it is imperative to understand those stories, for only then can the practice of medicine improve.

 

Three.

The idea of what is “right” – that is what can be proven true or is generally accepted as correct – is surprisingly complex, requiring a socially shared sense of “truth” and factual reliability.  A person’s ability to adhere to truth is a matter of integrity, and we expect higher levels of integrity from physicians, scientists, and engineers than many other occupations. Yet, shouldn’t we expect integrity in all responsible occupations, from chefs to politicians? When is it forgivable to tamper with the public trust for personal gain or malicious reason and what are the boundaries of the First Amendment? These tough questions are beyond solution in Matula Thoughts, but should be considered and discussed by all members of society.

It is a fact, as this line is written, that it is not raining outside my window, but that fact will change with time and environment. Some facts are difficult to ascertain and people sometimes have legitimate misconceptions of reality, uncertainty being intrinsic to humanity. Deliberate misrepresentation of reality, however, is corrosive to any social group and to society at large. Deliberate misrepresentation is expected in the products of fiction and the entertainment industry, but not in their business dealings. Misrepresentation in business, politics, religion, etc., erodes trust, essential for a healthy society. When stories become propaganda, or opinions masquerade as journalism, free speech is abused. Misrepresentation in medicine and science, worse matters, are social crimes.

These last charges are tricky, running contrary to the First Amendment and the cherished idea of free speech. Yet, “yelling fire” in a theater or its equivalent on social media is too  dangerous for society to tolerate. Democratic societies have yet to figure out where and how to draw the line between deliberate misrepresentation and free speech, and the hyper-pace of contemporary social media exacerbates the dilemma. Given that the ideas of the First Amendment are self-ordained “rights” of humanity, it is unlikely that they can be preserved if they cannot be better stewarded to serve the public, rather than serve individuals, factions, or ideologies.

Then, too, there is the matter of the “backstory,” the history, conditions, and other narratives leading up to a particular story and the circumstances that frame it. In health care the backstory includes co-morbidities, while in the field of economics such circumstances are dismissed as externalities. Although stories are simpler and easy to “understand” when stripped of complicating and confounding matters, stripped-down stories rarely convey the whole truth of a matter for accurate understanding.

 

Four.

It is hard to escape the name Oliver Wendell Holmes in American history. There were two of them, the first an iconic American physician (1809-1894) and the second, his son, an iconic supreme court justice (1841-1935). Both lives and careers centered on stories and truth.

Medical practice is a highly social profession and business. Socialization of practitioners with specialized knowledge and experience, sharing their stories, is a route to progress and today’s M&M conferences are programmed opportunities for this teamwork. Medical education, standards of practice, quality improvement, and research have been built around socialization since ancient times of Mediterranean and Asian medical practice, medieval professional guilds, and doctors in the early days of the United States.

One sparkling example was The Boston Society for Medical Improvement, doctors who wanted to share ideas and ascertain truths. Established in 1828 by John Spooner with 11 members, the Society quickly grew to 35 by 1838. Meetings were held the second and fourth Monday each month, originally in Spooner’s rented room on Washington Street.  A cabinet keeper managed a collection of specimens contributed by the members. Only “elite” practicing physicians of Boston were eligible and a younger set of physicians in 1835 formed their separate Boston Society for Medical Observation, echoing the terminology of Professor Louis in Paris, under whom Holmes studied. The two competing Boston groups ultimately merged in 1894.

The picture above, from the Countway Library Center for the History of Medicine, shows the Boston Society for Medical Improvement in 1853: sitting – George Bethune, Oliver Wendell Holmes, Samuel Cabot, Jonathan Mason Warren, William Coale, James Gregerson; standing – Charles Ware, Robert Hooper, Le Baron Russell, Samuel Parkman. Samuel Cabot was the grandfather of Arthur Tracy Cabot and Hugh Cabot, two of the most influential urologists in the transitional fin de siècle between the end of the late 19th century and early 20th. Hugh Cabot’s arrival in Ann Arbor in autumn 1919 defines the Michigan Urology centennial.

 

Five.

Puerperal fever & a murder. At a summer meeting in 1842 of the Boston Society for Medical Improvement, JBS Jackson queried fellow members their opinions regarding the possible contagiousness of puerperal fever. Jackson was concerned by the death of a colleague after treating an infected woman, and he knew of other infections incurred by subsequent patients the decreased physician had treated before he died. Holmes, a member of the original French Society of Medical Observation during his study in Paris a decade earlier, took up Jackson’s question and presented his own independent research, “The contagiousness of puerperal fever,” back to the Society on February 13, 1843. The presentation was commemorated in a 1940 painting by Dean Cornwell, That Mothers Might Live (below).

OWH 1843

The New England Quarterly Journal of Medicine and Surgery published Holmes’s talk in April and it was reprinted as a pamphlet (top, lead picture). Holmes was certain that “obstetricians, nurses, and midwives were active agents of the infection, carrying the dreaded disease from the bedside of one mother to the next.” This was among the earliest good evidence for germ theory of disease.

Holmes was dean of Harvard Medical School when he factored in the sensational murder case of wealthy Bostonian George Parkman in 1849. Parkman had studied medicine, but never practiced, so it is likely that the Parkman identified in the Boston Society for Medical Improvement was his relative. The murdered George Parkman was a wealthy Bostonian who had studied abroad, received an MD in Aberdeen, Scotland, and studied further in France, taking particular interest in mental illness. After returning home, however, he never practiced medicine, instead managed family property, so was ineligible for the Medical Improvement Society, although an admired friend of Holmes.

John Webster was also from an affluent family and had studied abroad. Later in Boston Webster became professor of chemistry and geology at the medical school, but ran into debt often and borrowed extensively, including from George Parkman. In an argument over a debt, Webster killed Parkman in his medical school office on November 23, 1849, dismembered the body, and hid it in a locked cellar basement restroom. An astute custodian, Ephraim Littlefield, concerned about the popular missing Bostonian, broke into the room and discovered the body remnants on November 30, 1849.  Holmes testified persuasively at the 12-day trial and Webster was executed by hanging on August 30, 1850. Holmes dedicated his 1850 introductory lecture to the medical school class in Parkman’s memory. [Below: OW Holmes c. 1879.]

Holmes enjoyed stories, although happier ones than that of his murdered friend. He wrote poetry and books of fiction and nonfiction. A founder of the Atlantic Magazine, he contributed to it regularly and mingled with the literary set in Boston, including J. Elliot Cabot, James Russell Lowell, Ralph Waldo Emerson, and Henry Wadsworth Longfellow. Holmes popularized the term Boston Brahmin and was certainly one of them. The Autocrat of the Breakfast-Table is a collection of 1857-1858 essays Holmes wrote for The Atlantic, published in book form in 1858. The stories are one-sided dialogues between a genial and “anonymous author” and other residents of a New England boarding house. It is, perhaps, more than a coincidence that the fictional detective imagined 40 years later by Dr. Arthur Conan Doyle, would share the Holmes surname.

 

Short story. Frédéric François Chopin born this day in 1810, six months after Holmes, lived a short life of only 39 years. Although numerous photographs exist of Holmes, only two exist of the great Polish composer and virtuoso pianist. [Below: top, Chopin c. 1847, http://commons.wikimedia.org/wiki/File:Chopin1847_R_SW.jpg]

Photography as a technology was new and rare during the early lives of these two men, but Holmes’ luck of longevity gave him greater opportunity as a subject. [Above: Chopin c. 1849. Daguerreotype by Louis-Auguste Bisson.]

 

Thanks for reading Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

 

 

February 1, 2019

DAB What’s New Feb 1, 2019

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Sands of time, transition, & short thoughts on rules
3996 words

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One.

time

February, the shortest month, begins today, this Friday, and its periodic extra day comes next year on a Saturday. Although 2019 is only a month old, the sands of time slipped away for one iteration of Michigan Urology, and the metaphorical hourglass reloads today for our Michigan Urology version 8 that will refresh our department. Regental privilege requires that the next urology chair requires formal action, although most of us know the party in question, who begins today as acting chair. Ganesh Palapattu will do an excellent job leading the faculty, residents, and staff – the parties who will actually do the refreshing. Our new chair will face challenges and, if history is any guide, our team will support him fully for the next chapter of the Michigan Urology journey. In that context, this is a good time to examine the past and re-articulate our history, as Richard Feynman (1918-1988), American theoretical physicist, once wrote:

“Why repeat all this? Because there are new generations born every day. Because there are great ideas developed in the history of man, and these ideas do not last unless they are passed purposefully and clearly from generation to generation.” [Feynman RP. The Meaning of it All. Thoughts of a Citizen Scientist. 1998.]

It may be a long stretch from the “great ideas in the history of man,” to a modest history of Michigan Urology but I hope you allow Matula Thoughts some slack and accept this belief in regularly rearticulating the past for each cohort of our successors.

screenshot 2019-01-29 14.12.14

I first met Ganesh when I was visiting professor at UCLA, my urology alma mater, and he was a resident under Jean deKernion, a wonderful urologist, leader, and friend. As a visiting professor at a number of places, I often tossed out ideas for papers, but Ganesh was perhaps the only one over the years who took the bait and completed a paper with me. His career took him to Johns Hopkins, The University of Rochester, and then Baylor in Houston at Tim Boone’s program. At great loss to Tim, but with his consent and blessing, Ganesh and his lab, with Alex Zaslavsky, came to Michigan at the start of my term as chair. Ganesh is well prepared. He is a terrific teacher, effective leader, excellent surgeon, and has led our largest urology section, uro-oncology, very well. When a need is identified he steps up – he was among the first to volunteer in Flint at the Hamilton Community Health Network clinic, when that opportunity materialized. His lab has done well with a recent 2% score on its latest grant submission. Ganesh will be thoughtful, consensus-building, and creative as he leads Michigan Urology in its mission (education, research, and clinical care), and our essential deliverable – kind and excellent patient-centered care. [Above: Ganesh with Anu. Below: with Kirtan and Elina.]

 

Two.

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Anticipating the centennial of Michigan Urology, we’ve been working on a new volume of our story, previously written by the late John Konnak and urological scholar Dev Pardanani nearly 20 years ago. It is impossible to understand the urology story in Ann Arbor, without a larger sense of the story of our state, our specialty, and our university. It might be said that melodies of the past haunt the reveries of our stories, to tweak Hoagy Carmichael’s phrase. So, our story properly began around 11,000 years ago, well before Hippocrates and the known roots of medical practice, with the inhabitants of the Mound Builder and Woodland cultures who populated our geographical area after the last glacial period receded. The Holcombe beach site near Lake Saint Clair has evidence of Paleo-Indian settlement in that era and by the 17th century, Huron, Odawa, Potawatomi, and Iroquois people inhabited the region. Dates are difficult to ascertain, but legend, archeology, and solar eclipse history suggest that an Iroquois Confederacy of Five Nations around the Great Lakes formed by then. Those people surely suffered from urological problems and undoubtedly tried many remedies to ease their pains, although the ailments either dissipated or claimed the poor sufferers’ lives. [Above: Painting by Roy Lichtenstein, 1965. Below, Map of Five Nations, De Lisle, 1718. Darlington Collection, University of Pittsburgh.]

map_of_the_country_of_the_five_nations_belonging_to_the_province_of_new_york_and_of_the_lakes_near_which_the_nations_of_far_indians_live_with_part_of_canada_taken_from_the_map_of_the_lou

French explorers, beginning with Étienne Brûlé, around 1610, Samuel de Champlain, and later René-Robert Cavelier de La Salle, attempted to colonize the regional home of the Cayuga, Mohawk, Oneida, Onondaga, and Seneca who comprised the Iroquois Five Nations. The Tuscarora joined the confederacy in 1722 to become the Six Nations that eventually were overwhelmed by Europeans.

 

Three.

Prelude to UM. Detroit, a settlement town in the western territory of a young United States, was initially referred to as the straights. Michigan became a distinct territory, carved from the Northwest Territory by congressional act, 30 June 1805. First governor William Hull and presiding judge Augustus B. Woodward described its history, in their first report, with the French penetration of Lake Michigan, the “Ouisconsin” River and the Mississippi down to its “mouth,” defaulting to the French feudal system of property ownership by aristocratic right (seigniorial), but offering no sensitivity to the Native American perspective:

“Prior to this era the settlements of the strait had commenced, and Detroit claims an antiquity of fifteen years superior to the city of Philadelphia. The few titles granted by the government of France were of three French acres in front, on the bank of the river, by forty feet in depth, subject to the feudal and seignoral conditions, which usually accompanied titles in France.” [Michigan Historical Collections. 36:107, 1908.]

The claim in the report refers obliquely to La Salle who buried an engraved plate and cross near what is now Venice, Louisiana, on April 9, 1682 to assert ownership of the territory by France. Hull and Woodward didn’t have all their facts in order regarding Philadelphia, also founded in 1682 but a month earlier on March 4 when William Penn made it the capital of Pennsylvania Colony. Great Britain assumed the French possessions after the 1763 Treaty of Paris ended the Seven Year’s War. Another Treaty of Paris, in 1783, ended the Revolutionary War, and the territory that would become Michigan was acquired from Canada by the United States. The Hull and Woodward Report tells of the sad circumstances of Detroit in June of 1805 just after it had burned to the ground:

“It was the unfortunate fate of the new government to commence its operations in a scene of the deepest public and private calamity. By the conflagration of Detroit, which took place on the morning of the 11th of June, all the buildings of that place, both public and private, were entirely consumed; and the most valuable part of the personal property of the inhabitants was lost. On the arrival of the new government [Woodward arrived Saturday June 29 and Hull on Monday July 1]. A part of the people were found encamped on the public grounds, in the vicinity of the town, and the remainder were dispersed through the neighboring settlements of the country; both on the British and the American side of the boundary… The place which bore the appellation of the town of Detroit was a spot of about 2 acres of ground, completely covered with buildings, and combustible material…” [Central Michigan University. Clarke Historical Library. 1805. Hull.]

Detroit rebounded from the fire and was on the upswing when The War of 1812 broke out and the town, indefensible, surrendered to the British on 6 August. An attempt to regain Detroit by General William Henry Harrison failed in January 1813, but on 10 September Commodore Perry’s fleet of nine small ships defeated six heavily armed Royal Navy ships on Lake Erie and returned the city to the United States. One quarter of the recruited American soldiers were African American. The British retreated up the Thames River in Canada, where the decisive Thames Battle on 5 October turned the tide against Great Britain and Tecumseh’s Confederacy (recounted here in Matula Thoughts last year). This story is a prelude to the University of Michigania, organized in Detroit in 1817.

 

Four.

New Year resolutions have faded into memory by now for all but the most resolute of us, although it’s worth reflecting that resolutions and intentions reflect the best versions of our imperfect selves. Franklin Delano Roosevelt, an architect of some of the best of modern American society, was particularly good with his public words, few more noteworthy than in his First Inaugural Address on March 4, 1933 during the depth of the Great Depression: “So, first of all, let me assert my firm belief that the only thing we have to fear is fear itself – nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance.” Yet, no more or less imperfect than most of us today, FDR sometimes crumbled from fear himself, as early in WWII with Executive Order 9066 February 19, 1942, authorizing the Secretary of War to prescribe “Military Areas”:

“Whenever he or any designated Commander deems such action necessary or desirable, to prescribe military areas in such places and of such extent as he or the appropriate Military Commander may determine, from which any or all persons may be excluded, and with respect to which, the right of any person to enter, remain in, or leave shall be subject to whatever restrictions the Secretary of War or the appropriate Military Commander may impose in his discretion. The Secretary of War is hereby authorized to provide for residents of any such area who are excluded there from, such transportation, food, shelter, and other accommodations as may be necessary, in the judgment of the Secretary of War or the said Military Commander, and until other arrangements are made, to accomplish the purpose of this order. The designation of military areas in any region or locality shall supersede designations of prohibited and restricted areas by the Attorney General under the Proclamations of December 7 and 8, 1941, and shall supersede the responsibility and authority of the Attorney General under the said Proclamations in respect of such prohibited and restricted areas.” [Below: FDR at Yalta. DG Chandor portrait at SAAM, Washington.]

chandor. fdr yalta

The Executive Order quickly became actual law on March 21, 1942 when Roosevelt signed Public Law 503, put forth by Congress after 30-minute discussion in the House and an hour in the Senate, thus evicting 122,000 men, women, and children of Japanese ancestry (two thirds were American citizens) from their West Coast homes to incarceration camps. Americans of German and Italian ancestry were similarly targeted, but with much smaller numbers. Another Executive Order, number 9102 signed 18 March 1942, created the War Relocation Authority (WRA) to manage the forced relocation and internment. Milton Eisenhower was its first director, but only for a few months. His successor, Dillon Myer asked Eisenhower if he should take the job and was told:

“Dillon, if you can sleep and still carry on the job my answer would be yes. I can’t sleep and do this job. I had to get out of it.” [NYT 3 May 1965.] [Oral history interview with Dillon S. Myer. Harry S. Truman Presidential Library.]

Ultimately, 18 Civilian Assembly Centers, 10 Relocation Centers of the WRA, 9 Justice Department Centers (with German-American and Italian-American detainees), 3 Citizen Isolation centers (for “problem inmates”), 3 Federal Bureau of Prisons sites (mainly for draft resisters), 18 U.S. Army facilities, and 7 Immigration and Naturalization Services’ facilities were involved in detentions. The Japanese American Memorial to Patriotism During WWII revisits this sad story with the Golden Crane sculpture of Nina Akamu showing two Japanese cranes caught in barbed wire. Semicircular granite walls name the ten main WRA internment camps and The Archipelago on the open perimeter along Louisiana Avenue near D Street in Washington, DC, symbolizes the Japanese Islands and the five generations of Japanese Americans affected by the war. [Below: Two Cranes. DAB January, 2018.]

japanese monument

 

Five.

Hourglasses turn the ephemeral notion of time into physical reality. The grains of sand are elementary chemicals assembling by physical rules into worthy objects, stardust like ourselves. Laws of chemistry and physics that created stardust are durable and universal. Human rules are fungible and we hope that representational government and good leaders bend them to fairness, allowing redress when rules are improper, archaic, wrong-headed, or harmful to the public good. All sorts of rules, federal, state, local, professional, organizational, sectarian, familial, and personal ones constrain us, and sometimes they seem to come out of the blue as with presidential directives. Lincoln’s Emancipation Proclamation, considered here last month, and FDR’s Executive Order 9066 raise the issue of these curious sidebars of American law. A report of the Library of Congress, Congressional Research Service, by legislative attorney John Contrubis (updated March 9, 1999) explains the origin and usage of these two “Presidential instruments” (below).

pres proclam

The Constitution provides no explicit authority for executive orders and proclamations, although Article II states: “the executive power shall be vested in a President of the United States,” “the President shall be Commander in Chief of the Army and Navy of the United States,” and “he shall take care that the laws be faithfully executed.” Dogmatic originalism, might then argue to exclude the Air Force from presidential authority, or stipulate that a president execute all laws faithfully to their letter (rather than broad interpretation of Constitutional intent), or that a president must be a “he.” Such pedantic exercises unnaturally infuse human rules with an immutability similar to natural laws of chemistry and physics.

emanc proc

As humans, we elevate some of our laws to higher truths, such as belief in human liberty, the sanctity of life, equality of opportunity, and the right to pursue happiness, recognizing that these “self-evident truths” are perhaps on a higher plane than laws of prohibition, zoning, speed limits, or executive orders. Executive orders are legally binding directives given by the president to federal agencies in the executive branch, while executive proclamations may be ceremonial, policy announcements celebrations (Mother’s Day), or statements of a condition (e.g. of national mourning for the death of George HW Bush). Clearly there is overlap between orders and proclamations; the Emancipation Proclamation was as much an order as a proclamation. [Above: Emancipation Proclamation, Clements Library, University of Michigan. Below: 1914 Proclamation of Woodrow Wilson designating Mother’s Day.]

mother's day proclamation copy

 

Six.

Lysekno. Civic laws can cast long shadows that undermine education and science, setting human laws and policies at odds with the natural world. The Trofim Lysekno (1898-1976) story is a cautionary tale. That Russian biologist rejected Mendelian genetics and proposed his own theory of environmentally-acquired inheritance, offering experimental results with improved crop yields by his methods (unverified by others) and convincing Joseph Stalin to embrace Lysenkoism nationally. Soviet scientists who opposed the idea were dismissed from their posts, if not killed as “enemies of the state.” [Fitzpatrick S. Stalin’s Peasants: Resistance and Survival in the Russian Village after Collectivization. Oxford University Press. 1994. p. 4-5.] Forced collectivization and famine followed in the 1930’s, but Lysenko’s political power consolidated and in 1940 he became director of the Institute of Genetics of the USSR Academy of Sciences. In 1948, scientific dissent from Lysenko’s theory was outlawed.

After Stalin died in 1953, Nikita Khrushchev retained Lysenko in his post, but scientific opposition resurfaced and his agricultural influence declined. In 1964, Andrei Sakharov (1921-1989) physicist, architect for the Soviet thermonuclear bomb, but later Soviet dissident and Nobel Peace Prize Recipient (1975), denounced Lysenko to the Russian Academy of Sciences in 1964 saying:

“He is responsible for the shameful backwardness of Soviet biology and of genetics in particular, for the dissemination of pseudo-scientific views, for adventurism, for the degrading of learning, and for the defamation, firing, arrest, even death, of many genuine scientists.” [Norman L, Qing NL, Yuan JL. Biography of Andrei Sakharov, dissent period. The Seevak Website Competition.] [Cohen BM. The descent of Lysenko. The Journal of Heredity. 56:229-233, 1965.] [Cohen BM. The demise of Lysenko. The Journal of Heredity. 68:57, 1977.]

Lysenko died in Moscow in 1976 with only brief mention in the daily national newspaper. His politically enforced scientific pseudo-science had tragic consequences for millions of people in Soviet Russia. Lysenko wasn’t the first to consider the effects of environment on inheritance, Lamarck (1744-1829) had that thought much earlier. Open scientific give and take has since shown that Mendelian and other genetic processes are indeed influenced if not largely regulated by epigenetic factors. Science works well, but not when corrupted by ideology.

 

Seven.

573px-the_gerry-mander_edit

Too bad Gerrymanders aren’t mythical creatures. These Homo sapiens look-a-likes actually exist, grabbing and abusing transient authority to distort reality and fairness to gain political advantage. Democracy as expressed in our origin-document, The Declaration of Independence is built upon shared belief in fairness, but when fairness is seriously undermined, authoritarianism creeps back into public life – authority of a political party, authority of a leader, authority of a particular ideology, authority of a religion, or authority of a class of people. History shows this human propensity again and again with tribalism, kingdoms, monarchies, dictators, cults, single-party nations, etc. Gerrymander came from Elkanah Tisdale’s cartoon in the Boston Centinel, 1812, showing the district created by the Massachusetts Legislature to favor incumbent Democratic-Republican candidates over the Federalists. [Above: Tisdale’s creature in the Centinel, 1812. Below: Michigan districts.]

 

mich congressional

Eradication of the gerrymander is one of democracy’s existential necessities. This problem is exacerbated by the algorithmically-targeted misinformation made possible by personal data mining. This perversion of free speech is dramatized in the Netflix film, Brexit.

 

Eight.

history hall

History Hall. Along the passages connecting University Hospital, Frankel Cardiovascular Center, Rogel Cancer Center, and Medical Sciences I buildings are pictures of most of the Medical School graduating classes. Even as faculty and staff walk briskly through them, discussing their work, the decorative walls and the light from the glass tunnel are pleasant and even refreshing. If you have a chance to linger briefly and look, the pictures take your walk through a history of paradigm changes, economic booms and busts, great discoveries, inspiring leaders, wars, bad actors, duds, and all the other stuff of 170 years. Each student and faculty member in the class pictures is an individual summation of countless personal dramas and stories. [Above: David Fox and Joe McCune.]

Maybe stepping aside as chair (I don’t think of it so much as “stepping down” or a loss, but I am truly pleased to have Ganesh Palapattu pick up the challenges, present and ahead) gives me too much time for lingering walks and gratuitous thoughts. Framed by all the larger problems of the world (geopolitical conflict, terrorism, poverty, widening inequality, economic unpredictability, environmental degradation, infectious diseases, and other existential threats) one must wonder: can we humans successfully control our own destiny? If so, some structure and rules are obviously necessary for 7 billion people on a small planet, but will the structures and rules revert to ancient painful models of authoritarian rule and pyramidal hierarchy, or could they tilt toward libertarian, laissez-faire, or anarchistic models although those have never proven successful at large scale?

The question is not merely rhetorical, it is existential and an answer needs to be found between those extremes, within some central range. How we find, set, and reset that optimal place in our laws is the ultimate political question. Representational democracy, even as terribly imperfect as it is, seems to offer the best framework to balance individual freedom and happiness with optimization of societal function, human destiny, and planetary sustainability. This same dilemma of governance, structure, and rule-setting is recapitulated in localities and large organizations, even that of Michigan Medicine. These may seem strange Matula Thoughts for the moment and solutions are beyond the wisdom of this writer, but with 7 billion points of wisdom, good answers should abound. Lingering walks through history halls can help.

 

Nine.

Academic urology at Michigan effectively began in the autumn of 1919 when Hugh Cabot came to Ann Arbor, and for that reason we begin a year of centennial celebration with our Nesbit Alumni Reunion October 3-5, 2019. Cabot’s 11 years at Michigan were transformative, but disruptive and (yes) often authoritarian, leading the regents to dismiss him in February, 1930, “…in the interests of greater harmony.” His next phase of work was at the Mayo Clinic where he focused on large issues of health care, such as testifying to Congress in favor of multispecialty group practice against the position of the AMA. Cabot’s final book, The Patient’s Dilemma, written in 1940, concludes with reflections on the problems that democratic systems have in planning the future. “It may well be – if we preserve our sense of humor – that we may suspect that the phrases ‘long distance planning’ and the ‘democratic process’ are in fact contradictions of terms.” While allowing for individual freedoms of opinions and rights to change them and exercise them through voting, Cabot explains that a democratic society that cannot make long term plans and carry them out is reduced to an “absurdity.” Cabot ends the book thus:

“…we have an immense body of opinion, part of which is in this country, a handsome part of it elsewhere, which continues in spite of discouragements, to believe that there is in all human beings an inherent and irresistible desire for certain freedoms which can be obtained only under democracy. Such a view seems to me based upon irrefutable evidence going back to the beginnings of the world. Its validity I cannot doubt. Once we admit this premise, once we admit that we believe that there are in democracy certain inherent benefits essential to progressive civilization, then we are driven to the conclusion that though long distance planning under democracy is beset with many vicissitudes, nevertheless such plans must be made and, by dint of good temper and the laws of the cosmos, they may come to fruition.”  [Cabot H. The Patient’s Dilemma: The Quest for Medical Security in America. 1940.]

 

Ten.

Stardust, Hoagy Carmichael’s popular song, came to his mind in 1927 when visiting his alma mater, Indiana University, where he had earned a bachelor’s degree in 1925 and law degree in 1926. Mitchell Parish added lyrics in 1929 and the song has been recorded by Bing Crosby (1931), Nat King Cole (1956), and Willie Nelson (1978) among many others. The music and the lyrics are equally compelling, with Parish linking “the purple dust of twilight time,” the stars, and memories of a lover: “And now my consolation is in the stardust of a song.”

The original title was two words, Star Dust. Astronomers have learned much about the topic since Hoagy’s day: the elements of stardust larger than hydrogen and helium up to the size of iron required solar furnaces for their creation, but larger elements required the greater manufacturing complexity of supernovae. The fact that life is literally made of stardust is not just a figure of speech, the stardust of a song is a lyrical metaphor of a higher order of magnitude. Lying somewhere between cosmic stardust and its human incarnation is the daily work and politics of humanity, and these have been the focus of matulathoughts.org.

I came to Ann Arbor in 1984 from Walter Reed and the U.S. Army at the invitation of Section Head Ed McGuire, who very positively impacted the world of urology and myself. I inherited the stewardship of Michigan Urology from another great urologist and our inaugural chair, Jim Montie. Previous leaders of urology at Michigan educated superb urologists from Nobel Prize winner Charles Huggins and Reed Nesbit, the first section head, through Jack Lapides who trained another splendid cohort, including Hugh Solomon whom we often see at Grand Rounds. [Below, Hugh and Jim.] Following Jack, we had Ed, Joe Oesterling, Bart Grossman, and then Jim. They all brought things to the table, so to speak.

screen shot 2019-01-16 at 7.47.03 am

My appreciation is profound to our faculty, staff, Nesbit alumni, and friends of the department. You have made my time as chair a joy. Sandy Heskett has been with me from the start of my administrative duties in Allen Lichter’s dean’s office and she has somehow dissolved the problems of each day and kept our department as well as your old chair on track. Jack Cichon and Malissa Eversole have been incomparable in their work and loyalty to our team. Thanks, too, to my colleagues and friends on the faculty, in the Dean’s office, and on central campus. It has been a great run for me, but it isn’t over yet.

We appreciate your interest and will be back here on the first Friday of March at this website: matulathoughts.org. and meanwhile encourage any comments from you.

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

 

Sun rise 2019

Matula Thoughts Jan 4, 2019

Sun rise 2019
3734 words

 

Periodic re-explanation. This column, Matula Thoughts, recalls ancient uroscopy flasks called matulas, used for centuries to examine urine for clues to illness. People want to know “what comes next,” a question, explicit or unspoken, dominating most conversations in medical practice: “can it be fixed and what will happen to me?” Remedy and prognosis mattered more than diagnosis in ancient days, when technology and verifiable medical knowledge were sparse, and understanding pathophysiology (using today’s terms) was not as useful to a patient as remedy and prognosis. Direct examination of urine, particularly for color change, was one of the few early tools of practitioners and the matula was the dominant symbol of the medical profession for over 600 years in western art, until Laennec invented the stethoscope in 1816.

As a monthly collection of thoughts, relevant and random, from a senior genitourinary surgeon, the title seems appropriate. This electronic column began nearly 20 years ago in Allen Lichter’s dean’s office as a weekly email called What’s New. After returning full time to Jim Montie’s Urology Department in 2007, we continued What’s New as a weekly communication, published every Friday by varying members of our department, except for the first Friday of each month when I claimed the electronic podium. A parallel version began 5 years ago on the website MatulaThoughts.org. Happily, the Department of Urology will soon have a new chair with forms of communication to better match the times and people of the next decade. Nevertheless, this monthly habit will continue at MatulaThoughts.org reflecting personal observations, relevant and irrelevant, and events related to Michigan Medicine and the Department of Urology. [Above: Sun face on ceiling fresco, church of Saint Jean-Baptiste de Larbey, Southwestern France. 1610. Wikipedia. Below: variant of Nesbit log by Julian Wan.]

 

One.

Imagine just 100 years ago how different things were for our predecessors at the University of Michigan Medical School: Americans were recovering from WWI and the first two deadly waves of the 1918 influenza epidemic; Woodrow Wilson was US president, having been Princeton president when he was offered the Michigan job ten years earlier; women couldn’t vote and any adult could drink alcohol on this day in 1919, but by the end of the year women’s suffrage was secured in the 19th Amendment and prohibition came with the 20th Amendment; socialist and communist parties were on the rise; anarchists were preparing for spring bombings; and racial tensions festered nationally. Meanwhile, the University of Michigan carried on with its work at the Medical School and University Hospital, as life went on in Ann Arbor. [Above: Approaching New Year’s Eve, December, 2018, Liberty & Ashley, Ann Arbor.]

The University in 1919, already more than a century old as an organization and in Ann Arbor for around 80 years, was amidst a building binge under President Hutchins with the new Union, Art Museum, Hill Auditorium, and other defining structures. The 60-year old Medical School, which had looked quite good to Flexner on his visit in 1909, had since fallen behind its peers in terms of facilities. The hospital was badly out of date well before the war and replacement was further delayed by the national emergency. The practice of urology at UM was a little more than a single faculty effort in a surgery department consisting of a handful of other individuals.

Late in 1919, Medical School dean Victor Vaughan recruited Boston urologist Hugh Cabot, who would engineer 11 years of change bringing the Medical School back to the top of medical education internationally and at the pinnacle of state-of-the-art clinical practice for the first time. Academic urology in Ann Arbor surely began with Cabot.

 

 

Two.

Pundits and ordinary folk made predictions and resolutions when the sun rose on 1919 and we repeated these customs three days ago. Events will happen and paradigms will surely change over the next 12 months, but the only solid predictions this posting will offer for 2019 are: a new chair will begin stewardship of this fine Department of Urology sometime soon and we will celebrate the Michigan Urology Centennial later in the year. Other than those predictions, the rest is noise (to borrow the title of the book on 20th century music by Alex Ross). Sunrise each new day or year brings uncertainty and new possibilities. Predict and resolve whatever you wish, paradigm changes are usually outside your control, although the ability to recognize their inflection points is a useful gift. [Below: Encyclopaedia Biblica, 1903. Public domain.]

The centrality of the Sun to life is a fundamental feature of biology and logically a universal symbol in human civilizations. The 14th century BC image of pharaoh Akhenaten (Amenhotep IV) worshipping sun god Ra, in form of Aten, shows a partial solar disc with rays ending in little hands. Curiously, Akhnaten (1983) was one of three biographical operas written by American composer Philip Glass, the other two being Einstein on the Beach (1976) and Satyagragha (in 1979, about Mahatma Gandhi).
Inevitably, an Anthropocene imprint was added to the sun, seen in the introductory figure from Larbey and much earlier in a 4th century BC marble relief of sun god Helios driving his chariot at the Temple of Athena in Troy. [Below: Pergamon Museum, Berlin.]

The man-in-the-moon, a whimsical anthropomorphic imagination, when combined with a solar face suggests the ancient Asian complementary opposites yin and yang. [Below top: Amiens, Bibliothèques d’Amiens Métropole, manuscrit Lescalopier (Fourth Day of Creation) c. 1200. Wikipedia. Bottom: yin and yang.]

 

Janus, Roman god of beginnings, looked to both the future and the past, presiding over transitions such as war and peace,  and might be viewed as a symbol of paradigm shifts in modern times . [Below: Janus, Vatican Museum.]

Solar symbols, seen on some national flags, are ubiquitous in the Happy Face, the mother and father of all emoji, designed by commercial artist Harvey Ball in 1963. Charles Kuralt’s Sunday Morning show, launched by CBS News on January 28, 1979, continues to employ a solar disk theme throughout 40 years of reiteration by Charles Osgood and Jane Pauley, remaining a pinnacle of news and civilized commentary as each episode rolls through a set of beautifully curated solar symbols. [Below: Sunday Morning (top) & Authentic Worcester Smiley (bottom).]

 

Three.

Isaac Newton’s big paradigm shifts began inauspiciously when he was born this day in 1643. His birth date in the old-style calendar was 25 December 1642, but Gregorian conversion brings his birthday to today in the modern calendar and solar year. Bad luck shaped him from the start; father died three months before he was born and mother commented that Isaac, ar birth, could fit inside a quart mug (Wikipedia). Mother remarried, but young Isaac, unhappy at home and bullied at school, reacted by focusing on his studies, becoming a top student at Trinity College in Cambridge. Apples, gravity, planetary motion, and mathematics come to mind at first with Newton’s name, which is also celebrated in the term for a unit of force.

Newton’s color theory was another product of his astonishing ability to think about the world and find clarity about how things work. Countless people before him had seen white light refract through glass prisms into the colors of the visible spectrum and everyone sees rainbows. Yet only Newton carried those observations into a theory of color, described in a book he wrote at 71 years of age in 1704: Opticks: or, a Treatise of the Reflections, Refractions, Inflexions, and Colours of Light. [Above: double Alaska rainbow. Eric Rolph. Below: Color wheel of Goethe. Wikipedia.]

Color theory continued to attract great minds, including German polymath Johann Wolfgang von Goethe (1749-1832) and Scottish scientist James Maxwell (1831-1879) whose differential equations in 1865 explained the electromagnetic spectrum. [Below, User:penubag, Wikipedia.]

An early Apple Computer symbol (above) was perhaps an intentional play on Newton himself and Adobe’s color disk (below) fragments color into infinitesimal gradients of hue.

 

Four.

Urine may not be a window to the soul, but it’s a useful indicator of disease through color, sediment, or odor. Red is an obvious hallmark of trouble, whether renal trauma, urinary stone, kidney cancer, bladder cancer, infection, BPH, structural anomaly, metabolic dysfunction, rhabdomyolysis, or genetic mutations. Ancient uroscopists expanded color change into fanciful imaginations and medieval uroscopy charts offered wild speculations of what color, sediment, consistency, smell, and taste of urine might portend in terms of prognosis. [Below: uroscopy clinic. Hortus Sanitatis. 1491, Mainz. Courtesy Dick Wolfe, Countway Library.]

The paradigm shift from uroscopy to urology occurred over two centuries replacing sensory examination of urine by eye, nose, and occasionally tongue, with microscopy and chemical analysis. Nevertheless, persistent uroscopic fortune-tellers claimed legitimacy even in the face of emerging scientific reason. Thomas Brian’s book in 1637, The Pisse Prophet, is a classic example of rational attempts to debunk dogma and fraud.[Below: Wellcome Library, 1655 copy.]

The metabolic dysfunction porphyria (named for purple urine) affected Scottish physician, Archie Cochrane, born 110 years ago in 1909 on January 12, and the prime advocate in modern times for evidence-based health care. Later this month Guilia Lane, our FPMRS fellow, will educate us on Cochrane in What’s New. [Below: normal urine sample on left and porphyria sample on right.]

This sample below from my clinic a few years ago was oddly green, but I failed to make note of the cause. Color still matters in modern urinalysis although, since matulas gave way to microscopy and chemical analysis, physicians rarely demand to view urine themselves before it heads to a machine or laboratory.

Macroscopic uroscopy gave way nearly completely to modern urine investigation with specific gravity measurement, chemical analysis, microscopic exam of spun sediment, bacteriologic culture, antibiotic sensitivity testing, and who knows what will come next. Twentieth century urinalysis was a cornerstone of urologic practice when it was unimaginable for a patient to leave the office of a good urologist without submitting a urine for examination. Hinman’s Eight Steps to Presumptive Diagnosis constituted the basis of urologic practice, at his start in San Francisco in 1920 as the first trained urologist west of the Mississippi: history, general examination, abdominal and external genital exam, urinalysis including a stained smear, prostate exam, plain x-ray, phenolsulfonephthalein test (PSP), and residual urine. [Bloom DA, Hinman F Jr. Frank Hinman, Sr: a first generation urologist. Urology. 61:876-881, 2003.] Color and other sensory inspection still matter and while details have changed, urology is diminished somewhat when its practitioners no longer personally inspect urine grossly and microscopically, favoring instead automated readout from machine or lab.

 

Five.

The story of urology at the University of Michigan was last told 20 years ago just after the Urology Section in the Medical School Department of Surgery emerged as a full-fledged department alongside its sibling disciplines of Neurosurgery and Orthopaedic Surgery. Much happened in the next 20 years to justify a new rendition of the story and additionally much more has been learned about the earlier years. The new book should coincide with the Michigan Urology Centennial, beginning later this year. Urology is a microcosm of modern specialized health care, but its roots are also of particular interest as the first designated medical specialty in Hippocratic times and the stories since then of the discoverers, progression of skills, and innovations that led to 19th century genitourinary practice and 20th century urology should be retold and interpreted for each new generation.

No story is ever complete, in its recollections of the past, because only partial relevant knowledge is known to any author and myriad other details of the cultural and physical soups surrounding those facts are mostly lost to historical recollection. Lucky historians may find, reconstruct, resuscitate, or recover useful details, but all stories are largely narratives of imagination and facts, whether true facts or otherwise, in the words of the late urological scientist, Don Coffey. Stories, even as particular as one of an academic urology unit, are enriched by the context of its people, events, and circumstances. For example, it’s inconceivable to consider urology at Michigan without understanding Moses Gunn, and any appreciation of Gunn requires the context of the Civil War. In that sense, the Michigan urology story aims to be rich in context.

 

Six.

The bicentennial edition of Howard Peckham’s sesquicentennial work, The Making of the University of Michigan, by Margaret and Nicholas Steneck is indispensable to understanding this institution. The Stenecks proposed, metaphorically, that this university began with a single strand that represented the foundational aim of the university to disseminate knowledge and embracing education at all levels. This strand thickened over time and became joined by a second strand, turning around the first one, the new strand representing knowledge itself, that must be interpreted, renewed, created, and disseminated through explorations, criticism, research, and invention. The Stenecks identified yet another part of the braid.

“Now there is a third strand wound with the other two. The University touches more than just its young students and faculty. It gives services to the State that help maintain it; it aids citizens who never enroll. These services began when its hospitals received perplexing cases from all over the State. It continued with the upgrading of high schools, the testing of municipal water supplies, with experiments in reforestation, testing programs for state highways. It supplied reading lists for club programs, lecture series for enlightenment, and musical concerts for entertainment. It expanded to research contracts for Michigan industries, development of new products for manufacture in Michigan, seminars for business executives, realtors and assessors, state college presidents, and refresher demonstrations for physicians and dentists. It provided radio and TV educational programs for all. Teaching–research-and service. These are the warp and woof of the University today.” [Peckham HH. The Making of the University of Michigan. 1817-1992. Edited and updated by ML Steneck and NH Steneck. University of Michigan. Ann Arbor. 1967, 1994. p. 1-2.]

A better term for “service thread” is that of public goods, and today those public goods extend far beyond the state of Michigan to the world at large. Universities, since the Middle Ages, have been the single entity in human society to attend consistently and dutifully, albeit imperfectly, to the human and planetary future. In the past few centuries the university, or the Academy as some call it, has extended from small Ivory Towers that educate a particular narrow subset of learners, to complex Multiversities with broader aims such as the Stenecks listed.

 

Seven.

Mission homeostasis. The University of Michigan entered the 20th century with a more complex, but clearer iteration of an academic medical center than it displayed at its start when medical education was the sole basis for its existence. The Chemical Laboratory in 1856 introduced the service of chemical analysis to medical education, clinical practice, and scientific discovery. A more complete linkage of medical education to clinical practice came with Michigan’s first university hospital in 1869 and by its third iteration in 1891 the triple mission of an academic medical center was fully in place, although confusion over priorities played out in such disputes as moving the medical school closer to large urban populations and hospitals, compensation of clinical faculty, and criteria for academic promotion.

Mission balance continued to confuse faculty and perplex leadership for that next century and into the present one. History brings some clarity to the matter: the University of Michigan Medical School began with an educational mission of training the next generation of physicians, research followed quickly initially to refine biochemistry in the service of the public, and clinical care was recognized as the necessary milieu for medical education and research. Among these three parts of the conjoined mission, clinical care is the moral epicenter, trumping any other part of the mission at any moment. Furthermore clinical care, a matter of complex intellectual teams, is the financial engine that currently underpins the other missions. Any great academic medical center must be first and foremost a state-of-the-art health care system that not only delivers excellent patient-centric service, but also studies and improves its systems of care and technologies along with its many scholarly and clinical disciplines. Clinical teams are the essential center and most important deliverable of academic medical centers. [Above: scribe’s heart measured against “feather of truth.” Book of the Dead, c. 1,265 BC. National Geographic, Ancient Egyptians. May 2009.]

 

Eight.

No Property in Man. January 15, 1929, the birthday of Martin Luther King, Jr., is celebrated later this month for his role in the slow, halting, and sometimes retreating movement towards universal human rights, a struggle that remains a very incomplete paradigm shift worldwide. [Above: MLK 1964.] Extending Mahatma Gandhi’s methodology of nonviolence and civil disobedience, King fought inequality through resistance that was nonviolent on his side of the bridge to change laws, public sensibility, and hearts and minds. Martin Luther King Day is celebrated around the time of Dr. King’s birthday, January 15, but the specific day this year will be January 21 according to the Uniform Monday Holiday Act. Michigan Representative John Conyers along with US Senator Edward Brook (MA) offered the first bill in Congress to honor King, but it fell short of passage by a few votes in 1979. In 1983, President Reagan signed the final bill to establish the day of remembrance, which commenced in 1986, also establishing a federal commission to oversee observance of the holiday. In 1989 President George HW Bush made Coretta Scott King a lifetime member of the commission. Toronto, Canada, Hiroshima, Japan, and Wassenaar, Netherlands also honor Dr. King with public observances.

We don’t close clinics, operating rooms, or phone lines for that day at Michigan (that would hardly have been in the spirit of Dr. King, anyway), but the occasion offers a time for reflection, study, relevant academic talks, and renewed efforts toward the unfulfilled paradigm shift to universal human rights. A good friend and Americana scholar, Jim Beuche, recommended a book called No Property in Man, by Sean Wilentz. In the spirit of this month, this is a “must-read” for 2019. Wilentz explains the issue starting at the Federal Convention (U.S. “Constitutional Convention”) in 1787.

“Descriptions of the Constitution as proslavery have misconstrued critical debates inside the convention. They have slighted the anti-slavery impulses generated by the American Revolution, to which the delegates, for better or for worse, paid heed. They have missed the crucial subtlety, which is this: although the framers agreed to compromises over slavery that blunted antislavery hopes and augmented the slaveholders’ power, they also deliberately excluded any validation of property in man.” [Wilentz. No Property in Man. Harvard University Press, 2018.]

Many forces assembled to abolish slavery in America, but Wilentz argues that the United States Constitution, the Republican Party (“an antislavery mass organization unprecedented in world history”), Proclamation 95 (Lincoln’s Emancipation Proclamation), and the 13th Amendment, legally abolished any legitimacy of the notion of “property in man” in America. [Below: page one of the five-page Emancipation Proclamation. National Archives.]

At President Kennedy’s suggestion, King led an effort to draft a Second Emancipation Proclamation, that would have outlawed segregation and expanded equality, but Kennedy’s Executive Order 11063 fell short of the draft. Lyndon Johnson’s Civil Rights Act of 1964, fulfilled more of King’s aspiration. That year King won the Nobel Peace Prize at age 35. He was assassinated in 1968 at age 39.

 

Nine.

Harvey Ball (1921-2001) designed the Happy Face to repair a decline in morale after the bumpy merger of two insurance companies. How effective the ideogram was in that instance is not clear, but Ball earned $45 for it and never applied for trademark or copyright. He never voiced regret for giving his symbol to the public, even after it became a universal symbol. Ball was born and raised in Worcester, Massachusetts, served in the Pacific Theater of WWII with a Bronze Star for heroism at Okinawa, started his own advertising company in his home town in 1959. One day, in 1963, he drew Smiley.

 

As a matter of law, copyright goes back to 1709 and the Statute of Queen Anne of Britain, the last monarch of the House of Stuart and the same Anne portrayed in the current film, The Favourite. Another current film, Mary Queen of Scots, portrays the start of the House of Stuart two centuries earlier, with the conception and birth of James, later first Stuart and first king to preside over England and Scotland.

The U.S. Constitution in 1787 includes a Copyright Clause (Article 1, Section 8), recently updated with the Copyright Act of 1976 and the Sonny Bono Copyright Term Extension Act of 1998, also called the “Mickey Mouse Protection Act” [Above: Queen Anne’s Statute. Below: Bell’s graph of US Copyright law expansion. “©1999-2008 Tom W. Bell. All rights reserved. Fully attributed noncommercial use of this document permitted if accompanied by this paragraph.” Wikipedia.]

Three days ago (Jan 1, 2019), according to U.S. copyright laws, all works published in 1923 entered the public domain. Sonny’s name was likely linked more to his music than his love of 1923 literature. (Wikipedia.) Works published then were to have entered the public domain in 1999, but were granted postponement by 20 years when Congress extended their copyright length with the Bono Act. Willa Cather’s A Lost Lady, Agatha Christie’s The Murder of the Links, Joseph Conrad’s, The Rover, Kahlil Gibran’s The Prophet, Marcel Proust’s The Prisoner (vol. 5 of In Search of Lost Time), William Carlos Williams’s The Great American Novel, and Virginia Wolfe’s Mrs. Dalloway in Bond Street were so reprieved.

[Above: copyright applied. Below: public domain.]

 

Ten.

Matula Thoughts analytics, 2018. We have no sense of the readership of the monthly What’s New delivered by email, but the web version, MatulaThoughts.org had 3454 views last year compared 3173 views in 2017. Viewers came from 89 countries, ranging from a few viewers in 35 countries, to 54 in Germany, 70 in the U.K., 87 in Canada, and 2578 in the US. Most views are cursory, but we enjoy hearing back directly from periodic careful readers who challenge our facts and alert us to errors.

[Above: analytics 2018.]
New Year 2019 began on a Tuesday and a short work week ends today for most people, but health care is a 24/7 business and by necessity we will offer more scheduled afterhours and weekend services at Michigan Medicine Urology, even though we have been doing so formally and informally for years. It is curious that most calendars begin each week on Sunday, although for most people that day is the end of the week and weekend, with the next week beginning at sunrise on Monday.

The 1902 fantasy film, Le Voyage dans la Lune, by Georges Méliés, shows an oversize spacecraft planted in the right lunar eye. We don’t have to travel 240,000 miles to stick it to a heavenly body, because Homo sapiens is doing this well enough right here at home on Earth, but possibly 2019 will be a turning point for planetary stewardship.

[Above: Schedel’s World History or Nuremburg Chronicle, 1493. Below: Earthrise, December 24, 1968. Apollo 8 astronaut William Anders.]

 

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

Sunrises, sunsets, & summer imaginations

Matula Thoughts Aug 3, 2018

Sunrises, sunsets, summer imaginations & facts

3951 words

One.

Michigan sunrises and sunsets are hard to beat this time of the year. [Above: Michigan sunrise: Campbell Cottage, Platte Lake, 6 AM July 9, 2018.] Regional newcomers find our summer nights come late, due to the fact that Michigan is about as far west and north as you can go in the U.S. eastern time zone. The western claim seems to be a true fact, at a tiny corner of Ontonagon County in the Porcupine Mountains, west of Silver City, Michigan (89.887453 west and 46.766675 north). The nearest named place on the map is Lafayette Landing, northeast along the Lake Superior shoreline (longitude 89.8407 west, latitude 46.7991 north) where August sunsets will be late and no doubt amazing.

Michigan still stretches further west to Gogebic County, but all four Michigan counties bordering Wisconsin are in the Central Time Zone (Gogebic, Iron, Dickinson, Menominee). If you extended the entire Eastern Time zone to a line drawn south from Lafayette Landing, the zone would incorporate Madison, Chicago, Memphis, Jackson, and Bogalusa, Louisiana (89.83881 west, 30.780556). Michigan comes close regarding the northern claim, but the most northern U.S. mainland place in the eastern time zone is actually Estcourt Station in Aroostook County, Maine, at a latitude of 47.4582 north with a population of 4, barely displacing Eagle Harbor in Keweenaw County, Michigan, at 47.45 north, 88.156 west (population 76).

However, if you are willing to navigate to Isle Royale National Park, you can expand the northerly  claim. Even better, Isle Royale has 450 minor islands and Gull Island may be the most north (48.2622 north, 88.26472 west). Rock of Ages Lighthouse is further west in Lake Superior, (89.3133 west, 47.86667 north), but not as west as Lafayette Landing. Possibly some real navigators could improve on these claims of fact, all derived from maps and Internet.

New house officers are a big academic feature of summer at the University of Michigan. We select them carefully and anticipate their arrival eagerly. This is sunrise for their most critical phase of medical training, graduate medical education (GME), where they learn the art, science, and skills of their careers as doctors, a phase more intense than medical school and may take more than twice as long. New trainees and new faculty (see item eight) regenerate our department and our field. Joining us as residents (postgraduate level 1 or PGY 1) last month: Kyle Johnson from University of South Carolina, Katie Marchetti from UM, Roberto Navarrete from Wake Forest, and Javier Santiago from Baylor. Joining us as fellows are: Giulia Lane from the University of Minnesota and Jeff Tosoian from Johns Hopkins. Their starting month was intense, after undergoing extensive onboarding processes, but their time off in Ann Arbor and environs should be pleasant with long sunny days to enjoy the Summer Festival, Art Fair, Farmers Market, Purple Rose Theater, Metro Parks, Detroit Tigers, restaurants, Manchester United vs. Liverpool at Michigan Stadium, and regional explorations, among countless other opportunities. All too soon daylight will shorten, work will intensify, as the full academic season unfolds next month and 2019 lines up in the batter’s box.

[Above: Lake Michigan sunset, Esch Road Beach near Empire, August 18, 8:43 PM 2011. Below: Sunset & rainbow, Grand Haven, July 22, 9:15 PM, photo credit, Carol Spahlinger.]

 

Two.

The term Michiganders surprised me the first few times I heard it after arriving in Ann Arbor in 1984 but now, accustomed to it, I occasionally use it myself. Michigander is a demonym, although a favorite author, John McPhee, didn’t include it among citations of other examples, such as Mancunians, Minneapolitans, Providentians, Haligonians, and Liverpudlians [McPhee. Draft No. 4. Farrar, Straus and Giroux, 2017. p. 173.] Sense of place matters deeply to most people, defining personal identity in large part. As much as Vonnegut deflated the notion of self-identification with organizations or geography, as for example being a Hoosier, pride of place memes are important. [Cat’s Cradle, 1963.]

In addition to its soccer team, Liverpool brings up memories of the Beatles, however pediatric urologists and pediatric surgeons of my vintage also think of Mr. Herbert Johnston (above, c. 1986), who practiced at the famed Alder Hey Children’s Hospital where innovations of safe prolonged general anesthesia advanced the range of pediatric surgery and urology. From its first public demonstration in 1846 until the mid 20th century, general anesthesia carried significant morbidity and mortality risks that increased with the duration of anesthetic time, so procedures had to be brief. With safe induction, tracheal intubation, controlled gas flow, and vital sign monitoring, surgical procedures grew in length and complexity. Blood gas, end-tidal CO2, and peripheral oxygen saturation measurement further enhanced safety and permitted extraordinary interventions including cardiac operations, organ transplantation, extensive cancer extirpations, and major bodily reconstructions. With operating rooms less tense and frantic, background music became commonplace and, given the popularity and sheer quantity of Beatles tunes, it is likely to hear them during surgery in operating rooms around the world today.

Soccer, or European football dominated many conversations in our department last month and in spite of the loss of his beloved British team the day before, Khurshid Ghani sportingly hosted a backyard viewing of the World Cup final between France and Croatia (below). Last weekend at Michigan Stadium, Liverpool defeated Manchester United 4:1 during their U.S. tour, jumping the Liverpudlian factor in operating rooms around the world from two-pronged to three-pronged when conversations turn to soccer, before or after, but never during “time-outs” of course.

 

Three.

The Chang Lecture last month connected me to Joel Babb, an artist living in Maine. Having spent many childhood summers in Maine I jump at the chance to reconnect there, obvious demonym notwithstanding. Joel’s depiction of the first successful renal transplantation, on display at the Peter Bent Brigham Hospital in Boston, was featured in our Chang Lecture, and Joel was very generous with permissions and digital files. He created the painting with the help of its principle innovator, the late Joe Murray, a close friend of my former professor at UCLA, Will Goodwin [Above: Joel Babb, self-portrait with dog, Ruskin. Below: Joe Murray visiting UM and a younger DABc. 1990.]

The First Renal Transplantation shows a large team of two operating teams and consultants necessary for that landmark event in 1954. [Below: study for First Renal Transplantation, Joel Babb.]

Joel sent us other examples of his work including the first face transplant in the Western Hemisphere, and a book by Carl Little, Nature & Culture, The Art of Joel Babb. [University Press of New England, 2012]

Medical care, initially a simple one-to-one expression of human empathy, has expanded to team-based efforts that blend science and the art of humanism. The balance is asymmetric according to teams, individuals, and locations. Organizational culture largely determines the blend, varying from day to day and hour to hour, as is true for most human efforts. Intrinsic to the humanism of medical care are principles of equity and kindness, although these are susceptible to submersion by political and economic milieus, whether based on consumerism, capitalism, socialism, or any other “ism” other than humanism. Some new meme of universal humanism is an existential necessity for our species, but it is expressed far too weakly and drowned out by larger themes of place and personal identity. That new meme must somehow embrace deep respect for all places and identities, but it seems sadly faint just now.

 

Four.

Place, whether urban space or landscape, has been a dominant part of Babb’s work and his surgical paintings seemed, at first glance, a departure. Sense of physical place gives familiarity and security, whether pastoral landscape, city, neighborhood, occupational, or particular health care location – operating room, ICU, emergency room. The human need for relevance makes us seek that sense of place in teams, although exaggerated sense of place, is destructive, leading to smugness, self-importance, or xenophobia. In the sense of teams, then, as place, Babb’s surgical paintings are really no departure from theme.

When sense of place is disrupted, particularly for reasons beyond an individual’s control, the disturbance must be unimaginable for those of us naïve to such grim experience. An astonishing statistic appeared in a recent book review in The Lancet by Jennifer Leaning: “One out of every 113 people in the world is either an asylum seeker, a refugee, or internally displaced, according to the United Nations High Commissioner for Refugees (UNHCR).” [The Lancet. 390:2136, 2017.] The book at issue, Refugee by Alexander Betts and Paul Collier, brings a new category of refugee into play in increasing numbers, the climate refugee. It seems that we owe it to ourselves, as a species, to secure safety of place – the idea of home – through our governments, and to mitigate it as best we can when we encounter its disruption. This should be a cardinal responsibility of the civilization we maintain for ourselves and build for our successors.

Disturbance of personal homeostasis threatens the most immediate sense of place, namely bodily place. Loss of limb, organ, or essential function carves away a person’s ultimate and closest geographic identity, the individual physical and mental place of self. The immediate human corporal reality, physical integrity, is our most fundamental place and we locate ourselves, we see ourselves most literally, in the image of our own faces. The face is the most essential part of identity, evidenced by facial recognition by self-learning algorithms. Loss of face, once an exaggerated figure of speech, is the penultimate reduction of “being.”

Joel Babb’s painting of the full face transplantation (above) demonstrates an extraordinary realization of human imagination and civilization, the capability to replace a human face. That painting carries his work across the spectrum of the human experience of place, from landscapes, to cityscapes, and then to the core visible essence of ourselves and its new mutability with full facial transplantation. For the story behind the face transplant, Joel referred me to an article by Raffi Khatchadourian. The patient, Dallas Wiens, was electrocuted in a boom lift when he contacted a high voltage line while painting a church roof in Fort Worth. [Transfiguration. The New Yorker. February, 2012.]

 

Five.

Imagination and reality go back and forth, and it is sometimes difficult to know the priority of chicken or egg. Human imagination has been wildly in play since our earliest days, as with the Lowenmensch chimera (above), a figurine from the Upper Paleolithic period (40,000 years ago) of a lion head on a man’s body, found in a German cave in 1939. One wonders what that artist was thinking while fashioning the figure, what god or superhero was imagined in the work. The Sphinx at Gaza, a more recent reverse example, with a woman’s head on a lion’s body.

The imagined miracle of transplantation is a related theme, wherein body parts could be exchanged. Saints Cosmas and Damian, twin Arabic physicians and Christian martyrs, practiced in the third century Roman province of Syria, now the town of Yumurtalik in Turkey. The story of their transplantation of an Ethiopian’s leg to a white man was their big miracle (Above: 16th century, Entstanden in Württembergisches Landesmuseum, Stuttgart, Wikipedia.). Details are sketchy, histocompatibility uncertain, but positive outcome must be inferred, otherwise how else could the miracle be explained?

The enduring meme of chimerism, returned with the zitiron, a mythical “merman” illustrated in Meydenbach’s natural history encyclopedia of 1491 (above: Wikipedia). The figure of a man-fish is suited up with armaments for battle. A more appealing chimera is The Little Mermaid story of Hans Christian Anderson in 1837 that reverberates in The Little Mermaid Statue, on Langelinie Promenade in Copenhagen, having survived vandalism, decapitations, and a 6-month sojourn in Shanghai. The story echoes again in Ron Howard’s 1984 film, Splash, with Daryl Hannah. [Below: Edvard Eriksen statue in Copenhagen, 1913]

As imagination informs reality, laboratory chimeras and body-part transplantations are now commonplace facts of life. I recently ran into colleague John McGee in a hospital corridor and noticed his chimeric lapel pin, the logo of his transplantation society. [Below: Dr. John Magee with pin.]

 

Six.

Challenged by modern medical practice, in technology-intensive specialties such as urology, residents and fellows may wish they could splice several contradictory heads on themselves to balance empathy and science, kindness and detachment, to better serve their patients. Our trainees can become adept at transplantation and making laboratory chimeras, but fundamental traits of humanity are more difficult to acquire and perfect.

Just after sending the May edition of this column, I came across a Piece of my Mind in JAMA by the well-known medical oncologist Marc Garnick, an oncologist who became a patient, reeling from bladder cancer and then confronting non-Hodgkin lymphoma the following year. His concluding paragraph captured my aspiration for our profession.

“The patient-physician relationship is unique among any other human experience, something to be understood and appreciated. By filling in the gaps and tending to the patient’s broader needs – not just those pertaining to diagnosis and therapy, but the fuller context in which treatment occurs, all of us – patients, physicians, nurses, hospital administrators, staff, and humanity – stand to benefit.” [Garnick. JAMA. 319:2079, 2018.]

This relationship is embodied in conversation that may merely begin and end with an initial “History and physical exam” moment, but might further develop over days, weeks, or years of a relationship. Whether limited to a single encounter or developed over time, that conversation has the potential to yield practical therapeutic value and even spiritual meaning to both patient and physician. I don’t mean to overstate or understate the idea of the conversation. It can be a mundane exchange of facts and desires from a patient, eliciting understanding and perhaps therapy from the provider. Yet, even at the simplest level, it is built on integrity and trust. If more ensues, so much the better.

 

Seven.

Chang Lecture notes. We began this series of talks in 2008 to honor Dr. Cheng-Yang Chang, who initiated a pediatric urology focus here in Ann Arbor. His father, Ku-nien Chang was a famous artist of the landscape literati style in China and Taiwan, and over 80 of his works are rotated through exhibits at our UM Art Museum, in the Shirley Chang Gallery. The lecture series was a particular enthusiasm of my term as chair and, expecting a successor, it seems suitable to conclude this series of talks, with great appreciation to all those who supported it with their interest and presence. In its way, the Chang Lecture series has fulfilled some part of our obligation as a university in offering things to public audiences – public goods.

Some shout outs are in order. Emily Soto has catered this event from the start. In the audience with many friends, colleagues, and members of our department were 2 former Medical School Deans, Allen Lichter and Jim Woolliscroft. Bob and Janet Bahnson came from Columbus with George and Tina Skestos. [Above: Emily, David, and daughter-in-law Aimee Soto with DAB. Below: Bob, George, Janet, Tina.]

George, three-time UM degree recipient, has the only Maize and Blue box at The Ohio State Horseshoe Stadium. Bob is former chair of urology at Ohio State, and Cheryl Lee, Nesbit alum 1997 is current urology chair. Hamilton and Lilly Chang joined us from Chicago, and Ted Chang and Mary Gallant drove from Albany. Our most distant attendee was Otto Lin from Hong Kong, industrial and systems engineer, although I suspect his main purpose in Ann Arbor was to visit his daughter, Associate Professor Ann Lin of the Gerald Ford School of Public Policy (below).

 

Eight.

Art Fair. With a new season of GME beginning in July we initiate our first major academic events during the Art Fair, starting with the Chang lecture on Art and Medicine late Thursday afternoon and then Duckett and Lapides lectures and teaching sessions on Friday morning, while the administrative staff simultaneously holds professional development training. Then, for most people, the afternoon is free as a sort of yearly “birthday present.” In this way, we drastically close down all but the most urgent clinical operations in the interest of education and recreation.

 

The John W. Duckett Visiting Professor began in 1997 in honor of a foundational figure in pediatric urology and friend and mentor to me as well of Michigan Urology. John had passed away unexpectedly and we began this series in his honor. Doug Canning of CHOP was our first Duckett lecturer and this year Rosalia Misseri, of Riley Children’s Hospital in Indianapolis, spoke about “Closing the loop: lessons learning by the pediatric urologist caring for the adult spina bifida patient.” The Lapides Lecture began in 2006 and this year it was given by Hadley Wood of the Cleveland Clinic, who has defined the field of urologic congenitalism. Her talk was “Applications and pitfalls in the use of video urodynamics in adult congenital neuropathic bladder.” Robust discussion with residents and faculty in attendance was robust and enhanced by the fact that Drs. Misseri and Wood had met the residents and fellows over the dinner the previous evening, while the Chang Lecture group had a simultaneous event at another site. [Above: Friday afternoon at the Art Fair. [Below: Hadley Wood with Rosalia Misseri and husband MortGreen, pediatric anesthesiologist at Riley.] Appended to this posting is a list of Chang speakers.

Peggy Duckett and George Drach, of Philadelphia have been with us from the start of this academic/Art Fair convergence. George and Peggy announced their engagement here in Ann Arbor to us on Jim Montie’s deck during the third Duckett Lecture season. George gives socioeconomic, philosophical, or practical talks during our Friday sessions, and this year spoke about the Urological Knife. If any readers want to know what that’s all about, he is available to give the lecture again.

[Above: Martha Bloom, George and Peggy.]

 

Nine.

Bomalaski Scholars. In 2014 Dave Bomalaski (Nesbit pediatric urology fellow 1996) and his wife Sue (above) generously endowed a recurring scholarship for a resident to explore a career in pediatric urology.

Julian Wan presented the award this year to Lauren Corona, PGY 3 (above & below). Previous Bomalaski scholars were Duncan Morhardt (Nesbit 2017), who is starting fellowship at Boston Children’s Hospital, Courtney Streur (Nesbit 2018), and Ted Lee (Nesbit 2019), who will follow Duncan to Boston in 2 years.

Two new faculty join us this year, both in the pediatric division – Courtney Streur and Bryan Sack (below). After training in Birmingham, Alabama, Courtney joined us for a 3-year fellowship with a masters degree in health services research. Bryan trained at Medical College of Wisconsin and then fellowship at Boston Children’s Hospital. [Devin & Courtney, Bryan & Melissa.]

Michigan Urology now has 7 pediatric urology faculty, 6 in endo-stone, 6 in neuropelvic reconstructive urology, 3 in sexual reproductive, 4 in general urology, 5 in community urology in Muskegon at West Shore Urology, and 13 in uro-oncology, and 4 faculty in our fulltime research cadre. Six faculty cover VA positions and we have multiple joint faculty with other departments, as well as a number of adjunct faculty.

 

Ten.

Diversity enriches nightscapes of Michigan, Maine, and all other places in innumerable ways. Tree frogs and lightening bugs are distinctive sounds and sights of Ann Arbor summer nights, starting up in June and disappearing around September. In the dark winter months, I’ll be longing see and hear them again. Diversity makes the natural world work, a fundamental fact obvious to any scientist or any other rational thinker. The most prominent living spokesperson for biodiversity, E.O. Wilson, visited Michigan as convocation speaker for our Life Sciences Institute (2004) and to receive an honorary degree (2009) as noted in our previous essays . I recently spotted this new portrait of him at the Smithsonian American Art Museum. [Above: by Jennie Summerall, 2006]

I hear frogs most summer nights when walking my dog, Molly. The chorus frogs, genus Pseudacris, comprise a genus in the Hylidae family named according to their sounds (“false locusts”) and the Northern spring peeper (Pseudacris crucifer) may be the noisy males I hear, advertising their social interests by means of their ancient social media. The Linnaean system of classification divides life into kingdoms, phyla, classes, orders, families, geni, and species. Scientific nomenclature dictates that  names of taxa above the genus level (families, orders, etc.) should be in roman type, but those at genus level or below are italicized. Wikipedia explains that the order of frogs and toads, the Anura, is divided into three suborders: the Archaeobatrachia, Mesobatrachia, and Neobatrachia. That last suborder (neo=new, batrachian = frogs) accounts for most anurans and consists of over 5,000 species, some of which live in trees, the so called arboreal frogs. Many frogs around here belong to the Hylidae family. Twelve frog species are listed among the amphibians of Michigan, including the Cope’s gray tree frog (Hyla chrysoscelis) and the Gray tree frog (Hyla versicolor). The American green tree frog (Hyla cinerea), extensive throughout the southeast, may be emigrating north as climate changes. These are popular pets, although they don’t do well with frequent handling.

Fireflies, the winged beetles I see most nights, are scientifically classified in the Lampyridae family of insects among the beetle order, Coleoptera. Over 2000 species of fireflies exist worldwide and the light they produce is a cold light, nearly 100% efficient in that it produces no heat. The light flashes are its social medium for courtship, warning, or predation. The predominant firefly in the eastern U.S. is the Photinus genus and its flashes bring males and females together for mating at night. The female lays eggs on or in the ground a few days after mating, and hatching occurs 3-4 weeks later. The larvae feed in the summer and hibernate over the winter, underground or in bark or other sites of refuge. Another use of the visual language of fireflies is to warn predators that they taste badly and may be poisonous, due to the lucibufagins, defensive steroids similar to the cardiotonic bufadienolides in some poisonous toads. Some fireflies, notably females of the Photuris genus, mimic mating flashes of other species in order to attract and then devour the unlucky males that fly to them in expectation of a different outcome.

Beetles and fireflies may be prominent contributors to Michigan nights, but they are only a tiny part of the rich web of life seen, heard, or unnoticed as we pass through these summer months. Tunes from open windows of cars and houses, patios, or block parties, drown out the tree frogs, just as outdoor lights or July fireworks obscure the fireflies. Seeing the cold light flashes from my porch and hearing music in the air from a neighbor begged the question whether that beloved musical group had a spelling problem. In 1957 John Lennon’s first group, the Blackjacks, became the Quarrymen, so named after their high school, Quarry Bank. Paul McCartney, age 15, joined Lennon in July and in the following March brought along George Harrison. By January of 1959 the other original Quarrymen had left the group and the three remaining guitarists, then attending Liverpool College of Art, briefly took up the name Johnny and the Moondogs for gigs. Art school friend Stuart Sutcliff joined as a fourth guitarist in January, 1960, bringing a new name for the band, the Beatals, after Buddy Holly and the Crickets. They became the Silver Beatles in May and by August, they were simply the Beatles. Sutcliff left the band in 1961 after its second Hamburg period and Ringo Starr joined in 1962.

While the name of the Liverpudlian musical group may have had a link to insect nomenclature, the spelling variations remain unexplained, perhaps the educational fault of Liverpool’s Quarry Bank High School (now Calderstones School), pharmaceutical influence, or simply poetic license in Liverpool’s hot summer nights.

 

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

Appendix
Chang Lecturers
2008 James Steward, DPhil, UM.
2008 Mysoon Rizk, PhD, University of Toledo.
2009 Joel Howell, MD, PhD, UM.
2010 Shinming Shyu, MS, EMU.
2011 Thomas Cole, MD, MPH, UNC, Contributing Editor, JAMA.
2012 Charles Yeo, MD, Thomas Jefferson University.
2013 Richard Prager, MD, UM.
2014 James Ravin, MD, University of Toledo.
2015 Pierre Mouriquand, MD., Claude Bernard University, Lyon.
2016 Don Nakayama, MD, MBA, Florida International University.
2017 David Watts, MD. University of California, San Francisco.
2018 David Bloom, MD, UM.

Birthdays, graduations, and centennials

July 6, 2018

Birthdays, graduations, and centennials
3678 words

One.


In July we welcome new residents and fellows to our urology program (more about them in the next few months) and it’s a nice time for them to be in Michigan. Si quaeris peninsulam, that is if you seek a pleasant peninsula (as the state motto goes), this is the time of year to explore this double peninsula with its 65,000 inland lakes and bordering four great lakes. Michigan is an appropriate name, coming from Ojibwe, meaning “large water.” Indigenous people inhabited this area for millennia, until 17th century Europeans moved in and called it home. [Below: Wikipedia.]

We celebrated America’s birthday on July 4 (fireworks above), but Michigan’s birthday is open to debate. Michigan Territory dates back to June 30, 1805 and statehood declaration was January 26, 1837, but an actual “birthday” doesn’t seem particularly important, federalism trumping state particularism. Michigan gained its upper peninsula in 1836 after the Toledo War. Like the ridiculous and bloodless Pig War, described on these pages last month, the Toledo Dispute grew out of conflicting geographic identities that quickly escalated, although some blood was spilled in Toledo when a young Ohio man with a penknife stabbed a deputy sheriff from Monroe, Michigan during a scuffle. Resolution of the dispute by the US Congress, during the presidency of Andrew Jackson, awarded Ohio the Toledo Strip while Michigan gained its Upper Peninsula. Annual Buckeye vs. Wolverine or Spartan contests ritualize the Toledo dispute although, for all the existential threats facing our species today, it is ridiculous that a Michigander might hate an Ohioan or a Buckeye despise a Wolverine.

Like most biologic lifeforms, we are engaged in life-long tests for survival and relevance, the relevance reflecting the necessity of belonging to some thing. Hard-wired into our genes, honed by millennia of trial and error, is the need to belong to a pack, a clan, a team, a family, a school, a community, a nation, or some belief system. Kurt Vonnegut satirized that notion of identifying with an organization or a particular geography in his book Cat’s Cradle (1969), where pride of membership in the General Electric Company, for example, or being a Hoosier seemed ludicrous. While Vonnegut challenged the meaning of such belonging, our genes compel us to those memes of identity and our national, sectarian, and religious identities are the most compelling. Identity as “an American” certainly supersedes identity as a Michigander, but endurance as a species may require a much stronger identity meme, namely that of being a global member of Homo sapiens. How we get there is anyone’s guess.

 

Two.

Beginnings. The Fourth of July was an arbitrary choice. The Resolution of Independence, legally separating 13 colonies from Great Britain, was signed by the Second Continental Congress on July 2, 1776. Congress then attempted to agree upon a document to explain the separation. The drafting of The Declaration of Independence had begun on June 11 by a Committee of Five led by Thomas Jefferson. Congress saw an early draft on June 28, but controversy over wording continued to July 2 and spilled over until agreement was reached on July 4. Signatures by state delegates didn’t begin until August and were not completed for several months [Danielle Allen, Our Declaration. 2014.].

This ambiguity gives us some license to pick a starting year for Urology at the University of Michigan. Genitourinary surgery was most certainly practiced from the earliest days of surgery in Ann Arbor but modern urology, with its educational and investigational components, is something substantially more. The actual term, urology, was invented by Ramon Guiteras, a genitourinary surgeon in New York City who founded the AUA in 1902. His book, Urology, in 1912 was one of the first 20th century texts to define the field, followed in 1916 by that of Hugh Cabot (below) an internationally famed Boston surgeon, with Modern Urology.

Disillusioned by the mercenary nature of his practice environment, Cabot accepted a “fulltime salaried” position at the University of Michigan as Chair of the Surgery Department in 1920. He brought modern urology to Ann Arbor, became the Dean of the Medical School, built a great multispecialty group practice, and presided over construction of a 1000 bed hospital that opened in 1926. His first urology trainees, Charles Huggins from Boston and Reed Nesbit from California, did well in their careers, influencing urology, worldwide medicine, and international events. Considering the various options, it seems reasonable and convenient to declare 1920, the year Cabot came to Ann Arbor, as the starting point for the Centenary of Urology at the University of Michigan.

 

Three.

Public universities. When Cabot arrived in Ann Arbor, the University of Michigan was already more than 100 years old and differed from any other institution the Bostonian had experienced. Medical education in Boston had been based on medical school relationships with separate private and public hospitals. When the University of Michigan established its own teaching hospital in 1869, however, it invented a new and different model of medical education. This has become a wholly owned and operated integrated health system containing a full range of medical practice and a research enterprise that comprises a rich milieu for professional health care education. The University of Michigan is further unusual in that it is a public university (birthdate in 1817) that pre-existed its own state (birthdate 1837).

The facet of American Exceptionalism that may matter most in the long run will likely be the magnificent patchwork of higher education consisting of public universities, private universities, liberal arts colleges, technical schools, research universities, professional schools, community colleges, and faith-based colleges functioning independently to build tomorrow’s citizenry. This patchwork is quite different from a single higher education system managed by a central state.

Public and not-for-profit colleges and universities in this country are shaped not only by their particular institutional legacies, but also by their public responsibilities. Because we are a free country, an entrepreneurial and commercial side of higher education also exists, with ultimate responsibility to owners, corporate officers, and shareholders. This sector is not the strongest point of the American patchwork.

The public status of a university and health system brings particular constraints and responsibilities. Constraint starts at the top for Michigan with ultimate authority at the board of 8 publically-elected regents, responsible to the people of the State of Michigan. Each regent also brings an individual sense of the missions of the university and its health system, aligned to the interests of their political party. Public responsibilities of public universities reflect public needs and aspirations in a larger sense, and convey to their learners, employees, and patients.

Private universities and health systems have their own boards and ultimate responsible parties, with values, needs, and aspirations are not necessarily the same as those of public institutions and therefore may align differently with learners, faculty, and employees. Even so, their not-for-profit status gives them public responsibilities.

A few months ago, these pages quoted a short campaign speech of presidential candidate John Fitzgerald Kennedy on the steps of the Michigan Union at 2 AM October 14, 1960, laying the seeds for the Peace Corps. While, JFK didn’t seem to quite understand how public universities were “maintained,” his point that they had a higher purpose was well taken: ” Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it.”  [Full speech below.]

 

Four.

Centennial. It is fitting that new leadership of this department of urology will be in place as we celebrate the Michigan Urology Centennial. Ceremonial interludes of this sort allow reflection, alignment, and revitalization before stepping into a new period. For purposes of planning we can start our Urology Centennial at the Nesbit Reunion in the autumn of 2019 and close it at the Nesbit Meeting in the autumn of 2020, roughly corresponding to a year in the academic calendar, but giving Nesbit alumni and friends two chances to get back to Ann Arbor for scientific and social events. A committee is already at work on this, under the leadership of Dr. Meidee Goh.

Before entering our second century, I’d like to clear up a nagging misconception. State support of public universities is dwindling nationally and this is particularly true in Michigan. Furthermore, virtually no state appropriations come to the UM health system or its medical school, aside for payment of services. It is true that other public medical schools have state-funded salary lines for faculty, but this is not so at UM. Nonetheless, many well-meaning Michiganders think their tax dollars support Michigan Medicine and that misbelief has led to hard-feelings in the competitive world of health care. One excellent referring physician from mid-state sent a rough email message to one of our faculty after hearing the UM “would not accept” his patient. In this case it wasn’t that Michigan Medicine would not accept the patient, but rather the “narrow network” of a stingy private insurer would not include Michigan Medicine in its network because Michigan’s costs have indeed been higher than average. It didn’t matter that this patient needed a complex surgical operation that is not done in most hospitals. Kudos to the referring physician for getting angry on behalf of his patient, but the anger was misdirected and to add a bit of insult to injury, the physician believed his taxes supported Michigan Medicine (wrong) noting that we would have cared for the patient under Medicaid or without any insurance (correct).

 

Five.

 

Visiting another peninsula. I was guest at another great public medical school and urology department that recently celebrated its first centennial, the University of California San Francisco. Our two institutions share many features and a number of Michigan medical students, trainees, and former faculty populate UCSF Urology. Unlike Michigan Medicine, UCSF is physically separate from its parent campus, across the Bay at Berkeley. The UCSF teaching hospital was founded in 1907, the year after the San Francisco Earthquake, and was the first university hospital in the University of California System. Schools of Medicine, Nursing, and Pharmacy co-located with the medical school on Mount Sutro along Parnassus Avenue and, like Michigan, the Parnassus Campus outgrew its geographic limits. While we at Michigan expanded to North Campus, East Ann Arbor Medical Campus, and other sites, USCF is also expanding widely, most notably to its grand new Mission Bay Campus. [Above: UCSF teaching conference with residents and an attentive canine named Peanut. Below: UCSF Assistant Professor Lindsay Hampson, UMMS 2009, next to Professor Kirsten Greene.]

[Below: top, Anne Suskind, Nesbit 2014 UCSF Assistant Professor and faculty David Tzou; bottom, Thai cooking class lunch with residents Heiko Yang UMMS 2016, Chef Sunshine, Adam Gadzinski UMMS 2013.]

Similar to Michigan, UCSF Urology celebrates graduation of its chief residents and fellows with dinner for families, faculty, and the entire resident cohort. Junior residents gently “roast” selected chiefs, just as we do in Ann Arbor. David Bayne, one of the graduating chiefs, was quoted by roaster Ian Metzler (whom I had met a few years back on the interview trail) as having once said: “Academic medicine is like a pie-eating contest, where the prize is more pie.” [Below: David & Shani Bayne.]

[Above: Peter and Laura Carroll at the St. Francis Yacht Club.]

 

Six.

Michigan’s chief dinner took place at our Art Museum the following week in June. Our graduating chief residents and fellows join a fine tradition of urology education in Ann Arbor going back to 1926, after UM opened its University Hospital (the fourth since 1869) and Hugh Cabot brought the first two urology trainees to Michigan. Since then at least 329 urology residents and fellows have come from this program. The exact number remains elusive as we don’t have a full accounting of all the fellows or the residents trained at the historic Wayne County General Hospital branch. Khaled Hafez and Gary Faerber had superb runs as program director over the past decade and the reins now pass to Kate Kraft. Our new PGY1’s were on hand for the evening.

[Above: Kate Kraft introducing new PGY1’s Kyle Johnson, Katie Marchetti, Roberto Navarrete, & Javier Santiago. Below: Amy Luckenbaugh and parents.]

Graduating chief residents are transitioning to fellowships: Amy to Vanderbilt Uro-oncology, Amir Lebastchi to the NIH Uro-oncology, James Tracey to Guys’ Hospital Andrology & Reconstruction, and Yooni Yi to UT Southwestern Dallas Reconstructive Urology. [Below: top, Amir with family and friends; middle, James and family, bottom, Yooni and parents.]

Fellows: Duncan Morhardt to Boston Children’s Pediatric Urology, Elizabeth Dray Columbia SC practice, Tudor Borza to University of Wisconsin faculty, and Courtney Streur joins our pediatric urology faculty. [Below: Duncan and wife Tina; Elizabeth with father Greg and husband David; Courtney between Professors John Park and Daniela Wittmann; Tudor between Ted Skolarus and Jeff Montgomery.]

 

Seven.

Memes. A few months back we raised the idea of the meme in relation to the blind eye metaphor. A meme is a parcel of self-replicating information that, like the biological gene, is capable not only of replicating into perpetuity, but also can modify itself through time and cultures such that the fittest versions survive. Richard Dawkins invented the neologism in his book, The Selfish Gene in 1976, noting that the concept pre-existed his description. He postulated that if one fundamental principle existed for all life it would be “that all life evolves by the differential survival of replicating entities.”

“I think that a new kind of replicator has recently emerged on this very planet. It is staring us right in the face. It is still in its infancy, still drifting clumsily about in its primeval soup, but already it is achieving evolutionary change at a rate that leaves the old gene panting far behind. … The new soup is the soup of human culture. We need a name for the new replicator, a noun that conveys the idea of a unit of cultural transmission, or a unit of imitation. ‘Mimeme’ comes from a suitable Greek root, but I want a monosyllable that sounds a bit like ‘gene.’ I hope my classicist friends will forgive me if I abbreviate mimeme to meme. If it is any consolation, it could be thought of as related to ‘memory’ or to the French word même. It should be pronounced to rhyme with ‘cream’.” [Dawkins. P. 248-249. The Selfish Gene. 40th Anniversary Edition.]

That idea of the soup of human culture corresponds to the concept of superorganisms created by eusocial species, as E.O. Wilson has elegantly described in his work. Just as the gene is the building block of information that constitutes each individual, language and memes comprise the information that constitute the superorganism. Germ theory, shoe lace tying, tweetstorms, and the meme itself, are successful memes.

 

Eight.
The soup of human culture meme recalls a sensational episode of plagiarism involving Maurice Maeterlinck (1862-1949), Belgian author and Nobel Laureate (Literature, 1911). Well-known in his time, he had a stint in the United States produce film scenarios for Samuel Goldwyn in 1919, although none became a movie. One scenario was The Life of the Bee, although Goldwyn heartily rejected the idea of a movie about a bug. Back home in 1926, Maeterlinck published a book called La Vie des Termites (The Life of White Ants), although reportedly admitted he never actually seen a living termite. His source, boldly copied, was obscure work published in 1923 in Afrikaans by Eugene Marais, called The Soul of the (White) Ant. [Wikipedia.]

Extensive field work observing termites “on the veld,” led Marais to the idea of “the organic unity of the termitary” analogous to the organ-based composite human body. Maeterlinck appropriated the Marais theory 3 years later, boldly plagiarizing the text. Marais threatened a lawsuit although didn’t pursue it due to financial barriers. A subsequent English edition of Marais’s original book contains an introduction by its translator, Winifred de Kok assigned priority and credit to Marais, while pointing out the plagiarism. [Eugene N. Marais. The Soul of the White Ant. Methuen & Co. London. 1939.]

Tracking down the meme story, I found the Dawkins neologism and then noted the Maeterlinck transgression in Wikipedia, where University of London professor of biology David Bignell described the episode “a classic example of academic plagiarism.” Not wanting to fall into the realm of plagiarism myself, I tried to track down the evidence for this claim (after all, Maeterlinck was a Nobelist!) and went to the reference cited in Wikipedia but couldn’t find the actual claim. I did find an email address for Professor Bignell, composed my question, and pressed “send.” A reply from the next morning was a wonderful surprise. Professor Bignell wrote:

“Thank you for your message. This has rather made my day. I am long since retired, but it’s always stimulating to be dragged out of retirement with a question about termites, however obtuse. … The only public reference I have ever made to the Marais/Maeterlinck issue was in my Inaugural Lecture in October 2003. In the UK, newly promoted Full Professors are obligated to give a public lecture (widely advertised and open to anyone to attend), and I might add a terrifying experience as it’s your one opportunity to make a complete fool of yourself without any subsequent means of redress. I stuck to my subject (termites) but included a reference to the plagiarism, as it had become celebrated in the world of science, and bizarrely was one of the reasons why termites sometimes command public attention.”

 

Nine.

Mimes & plagiarists. Mimicry is the biological phenomenon in which one organism evolves characteristics that resemble those of another group. This is akin to a theatrical phenomenon, the performance art of acting out a story or a persona, the term coming from the masked dancer in ancient Greek comedy called Pantomimus. Marcel Marceau, French actor and survivor of the French Resistance in WWII, became the most famous meme of modern times and brought silent mimed exercises to a high art, inspiring Michael Jackson among others.

[Publicity photo of Marcel Marceau for appearance in Seattle, Washington, 1974. Wikipedia.]

[Mime artists Jean & Brigitte Soubeyran in the play “In the Circus” 1950. Wikipedia.]

As a young surgeon I tried to mimic attributes of my key role models. At UCLA they were William Longmire, Rick Fonkalsrud, Don Skinner, Rick Ehrlich, RB Smith, and Jean deKernion. In London it was David Innes Williams and in Boston, Judah Folkman and W. Hardy Hendren. Each set high bars for thinking, clinical acumen, surgical skill, patient rapport, teaching, and wisdom. Role modeling is essential to professional education, where the so-called hidden curriculum of behaviors is as important as the conceptual knowledge and skills that are imparted.

The truism that imitation is a high form of flattery, however, stops short of plagiarism. Plagiarism is theft of an original idea or work and representation of it as one’s own. Most work of civilization is collaborative with some decree of mimicry, but deliberate plagiarism betrays civilized behavior and represents fraud, theft, and deceit. Erosion of trust in science and medicine is particularly dangerous. Even though plagiarism seems to be a rare event in academic circles of urology, it happens. Most people can easily distinguish the difference between passing along memes and outright plagiarism. Science, literature, and the other arts build upon the imagination of our predecessors, and the memes they created or passed along replicate only through re-use, evolving in that reuse through the trial and error of application (or errors in transcription). The fairness of civilization demands that credit be given when credit is due, recognized through patents, copyrights, and academic integrity.

Plagiarism happens in a number of ways. Some people, unfamiliar with traditions of intellectual honesty and personal integrity, may resort to lazy plagiarism of an idea, paragraph, illustration, or even more. Other plagiarists rationalize that their “scholarly methods” allow cutting and pasting without attribution as “honest mistakes.” I’ve heard a number of these excuses even from a few otherwise respected colleagues when caught in the peer review process. On the other hand, when journalist James Stewart wrote his factual account, Blind Eye, he used a very widespread metaphor (a meme) for the dark and true story of educational supervisors who turned a blind eye to terrible misdeeds of an aberrant human being. [Blind Eye. 1999. Simon & Shuster.] Stewart, however, didn’t need to acknowledge Admiral Nelson for the meme, we would call that fair use, and such acknowledgement would border on pedantic explanation, when no explanation is necessary. Blind eye is now part of our language.

We all replicate memes, but gross plagiarism discovered occasionally during journal review makes me angry. It wastes the time of the reviewer and discredits our “brand” as scholars in the eyes of the public. We expect our resident graduates to mimic the best of what they observe and then to build on that to become their own originals in thought and action. Furthermore, we hope they will never turn a blind eye to plagiarism or other breaches of civility.

 

Ten.

Graduating urology trainees carry with them rich identification with their training programs and join unique cadres of fellow alumni that may reach back more than a century, as for Johns Hopkins, the first formal urology program. Most physicians identify reverently with their residency training sites. Human complexity allows us to find relevance in numerous contexts and, to that end, medicine as a generality for health care, is a greater belief system than mere occupation or specialty. More than most professions, medicine is central and essential to life and its fulfillment. We each begin life as patients, are among the rare species that routinely need assistance for childbirth, and we are the only species capable of complex therapies based on shared, verifiable, and accruing knowledge and technology. Medical practice is, above all, a performance art.

The art of medicine exists in the choices of excellence, kindness, attentiveness, education, innovation, skills, investigation, and fiduciary duty brought to the daily work of clinical care, and updated in daily practice through immersion in the soup of human culture. We extend that immersion through other forms of art, as the title of a book by Robert Adams provocatively claims. [Art Can Help. Yale University Press, 2017.] Visual, musical, and other performance arts inspire thought, admiration, criticism, inquiry, and further creativity. The arts help us answer our continuous tests for relevance as trainees, new graduates, and old hands in urology.

Thanks for reading Matula Thoughts this July, 2018.

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

 

Kennedy’s speech. When you listen to a recording it differs somewhat from this official printed version.

“I want to express my thanks to you, as a graduate of the Michigan of the East, Harvard University.
I come here tonight delighted to have the opportunity to say one or two words about this campaign that is coming into the last three weeks.
I think in many ways it is the most important campaign since 1933, mostly because of the problems which press upon the United States, and the opportunities which will be presented to us in the 1960s. The opportunity must be seized, through the judgment of the President, and the vigor of the executive, and the cooperation of the Congress. Through these I think we can make the greatest possible difference.
How many of you who are going to be doctors, are willing to spend your days in Ghana? Technicians or engineers, how many of you are willing to work in the Foreign Service and spend your lives traveling around the world? On your willingness to do that, not merely to serve one year or two years in the service, but on your willingness to contribute part of your life to this country, I think will depend the answer whether a free society can compete. I think it can! And I think Americans are willing to contribute. But the effort must be far greater than we have ever made in the past.
Therefore, I am delighted to come to Michigan, to this university, because unless we have those resources in this school, unless you comprehend the nature of what is being asked of you, this country can’t possibly move through the next 10 years in a period of relative strength.
So I come here tonight to go to bed! But I also come here tonight to ask you to join in the effort…
This university…this is the longest short speech I’ve ever made…therefore, I’ll finish it! Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign. I come here tonight asking your support for this country over the next decade.
Thank you.”
Senator John F. Kennedy
October 14, 1960

Spring and all

DAB What’s New Apr 6, 2018

Spring and all

3476 words

 

One.

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

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

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

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

 

Two.

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

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

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

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

 

Three.         

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

[Above & below: morels]

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

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

 

Four.

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

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

 

Five.

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

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

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

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

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

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

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

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

 

Six.

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

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

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

 

Nine.

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

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

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

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

 

Ten.

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

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

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

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

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

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

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

Why on the evidence of pictures is everything important?

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

 

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

Thanks for reading Matula Thoughts this April, 2018.

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

 

Marginalia

DAB What’s New Mar 2, 2018

 

Marginalia of sorts
3732 words

 

One.

Marginalia. As a young reader I recall making casual sideline notations in margins of my books and, in time, detailed marginalia, underlining, and highlighting expanded into my college and medical school textbooks. Later, during residency I heavily personalized my pages of Campbell’s Urology trying to digest them intellectually.

The habit persists and marginal notes help make sense of what I read and leave reference points to which I can easily return. Other reading has replaced textbooks my marginalia drifted to and consolidated on end pages, creating personalized indices of page references and related comments (below “end-page marginalia” in Harari’s Sapiens).

Marginalia-making has been a human habit ever since books existed with numerous famous examples as early as amusing marginal drawings by monastic scribes alongside their serious transcriptions. A notable marginal comment unsettled the world of mathematics for nearly four centuries after French lawyer Pierre Fermat wrote in the margin of a book he was reading in 1637 that he had solved a puzzling mathematical conjecture, but claimed his solution was too large to fit the margin.

The book was a 1621 edition of Arithmetica by 3rd century mathematician Diophantus and its actual margin looks generous by my standards, although I am no mathematician. [Above: Wikipedia, public domain.] It may never be known if Fermat’s solution was correct or if he was joking, although he didn’t seem much of a jokester and his other mathematical work was accurate. Furthermore, his unsubstantiated comment was taken so seriously that it was included in later editions of Arithmetica (below: Wikipedia).

Many others tried and failed to solve Fermat’s Conjecture over the next three centuries until 1994 when British mathematician, Andrew Wiles, came up with the answer.

Scribbling in the margins of library books or books of your friends is bad form, but marginalia in personal materials conveniently identify meaningful passages or record pertinent or tangential thoughts. Some mental process pauses readers from reading long enough to acknowledge the adjacent text in some way. Marginalia are evidence of our effort to find meaning in the things we encounter.

Electronic books allow similar personalizations, although it’s not quite the same, in part because electronic screens lack the comforting tactile sense of paper. Electronic formats, however, offer new opportunities and challenges for marginalia: private marginalia can become public, aggregated, and analyzed. Audio books allow listening as we close our eyes or move physically through life, but as much as I like audio books when driving, the opportunity to make marginal notes is problematic and any spontaneous thoughts I have when hearing certain passages are usually gone from memory by the time I’ve reached my destination.

 

Two.

The compulsion to annotate or otherwise leave personal evidence of one’s presence or thought pre-existed books and is widely exercised on other cultural artifacts and the environment-at-large. Cave paintings, rock carvings, initials on tree trunks, furniture inscriptions, children’s heights on door frames, and urban graffiti are footnotes of ourselves and plant notice of us for the future. The cliché George Washington Slept Here was a 1942 play and film about a couple who moved into a run-down farmhouse (because of their dog) and they discover the first president actually stayed there during the Revolution.

The top of this posting shows a section of the Berlin Wall that faced the free part of the city, while below you see the unmarked reverse side that faced the Soviet side. These sections are on display in Washington, DC at the Newseum and were salvaged after the wall came down in 1989. The contrast is stark.

Urban graffiti, as annoying and vulgar as it can be, are an expression of personal freedom and the 45 words of the First Amendment that represents a core belief of our representational democracy.

“Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.”

A video display at the Newseum displays interviews on a random street showing that people are far more likely to be able to identify all the members of Homer Simpson’s cartoon family than to know the five freedoms of the First Amendment (religion, speech, press, assembly, and petition of the government). The video references national surveys that support this unfortunate observation showing 20% of Americans can recall all Simpsons, whereas only 3% know all five freedoms.

The marginalia habit fills the strong human compulsion to seek relevance and meaning, a need played out in many ways including early forms of social media content; “Kilroy was here,” “George loves Tina,” and their equivalents have been expressed by our species since the earliest human days. Graffiti as urban social marginalia, occasionally becomes valued public art such as the works of anonymous British artist known as Banksy. [Below: a Banksy image from Wikipedia.]

Historical plaques and other public commemorations are structural marginalia, we mentioned those of the old Ann Arbor Bus Station, last month, on the Residence Inn in downtown Ann Arbor. Historical markers are marginalia of place. You can find plaques at the Michigan Union on the top front landing step and on the building wall commemorating the first occasion that John F. Kennedy publically articulated the Peace Corps idea. It was during a campaign speech October 14, 1960 at around 2 AM, a remarkable time for a presidential campaign speech that highlighted the vigor of the young presidential candidate. Arriving from New York in those early hours he went directly to the steps of the Union where a crowd of around 5000 students was waiting on State Street. Kennedy began his remarks by describing himself as “a graduate of the Michigan of the East, Harvard University.” He spoke about the importance of public service, asking for young doctors and engineers, as an example, to spend a period of time in Ghana or other places. You can find the speech on YouTube and he concluded:

“I come here tonight to go to bed, but I also come here tonight to ask you to join in the effort! This university – this is the longest short speech I’ve ever made and therefore I’ll finish it. Let me just say in conclusion that this university is not maintained by its alumni or by the state merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose and I’m sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign, I come here asking for your support for this country in the next decade.”

It was an inspiring speech. As an aside, the official portrait of Kennedy (above: painted by Aaron Shikler, whom Jackie Kennedy selected after the assassination) is on display at the Smithsonian National Portrait Gallery, along with all presidents up through Barack Obama (recently unveiled). The Kennedy portrait is the only image of a president looking down and away from the viewer, that having been Jackie’s choice.

Kennedy’s idea continues to tap into a compulsion for relevance and meaning that many students and others feel so acutely. The Peace Corps, finalized in law in the first months of his presidency, continues to resonate with college students across America. Since 1961 Michigan has been among the top four contributors to the Peace Corps with 2720 students volunteering since 1961 (after Berkeley, Madison, and Washington. [Mandira Banerjee. Feb 21, 2018. The University Record.]

 

Three.

Eleven years ago today, 2 March 2007, was the second day of my time as chair. Going to my computer I found digital images from that time in our department, including this early picture (above) of the board in my office. This has served as my functional marginalia for the Department of Urology for the past 11 years. Faculty are in the boxes on the sides and activities, units, and projects in the middle. The board changed over the years as we grew and became more complex. The picture below shows one of our visits to the billing center in the KMS Building south of I 94. Jack Cichon (now retired) was our stalwart Chief Department Administrator (CDA) and Malissa Eversole was then his understudy, having since then come into her own as our current CDA.

Below you see Ed McGuire in the center with 2 of his former fellows (now faculty) on the left (Anne Pelletier-Cameron and Quentin Clemens) plus Stu Wolf (faculty) and Walter Parker (resident) on the right.

Since 2007 the changes in healthcare education, research, and clinical delivery have been head spinning. Today the UM Medical School and health care system is rebranded as Michigan Medicine.

The time has flown by, in my mind, and if this present interval of stewardship of the Department of Urology is deemed successful in any measure, the success is due overwhelmingly to our faculty, our residents, our nurses, our physician assistants, our researchers, and our staff. Sister departments in the Medical School and this great University also account for our success; we flower in fertile soil.

This success should continue to grow with our next departmental leader whom I hope will help our clinical divisions and team do their jobs optimally, as I have tried to do. We want to avoid a repetition of the darker events of the 1990’s (as duly recorded in the Wall Street Journal and the Detroit Free Press), when Ed McGuire’s successful term and Bart Grossman’s interim stewardship were interrupted by a few difficult years until Jim Montie’s leadership brought us into departmental status and initiated the Dow Health Services Research Division. [Below: Khaled Hafez, Hugh Solomon, Jim Montie.]

 

Four.

March brings Spring steelhead to mind. It’s been many years since I’ve been on the Pere Marquette River thigh deep in waders feeling the rush of icy water working its way toward Lake Michigan. Migrating steelhead salmon, pressing retrograde to reconcile with their past, have few things on their minds at that stage and feeding is not high in their priorities. Lures need not be very sophisticated or authentic, as the fish are on their migration to spawn so they are as likely to bite out of anger or random habit than culinary urge. [Above: Brent Hollenbeck and steelhead. Photo credit: Jeff Montgomery.]

Steelhead rainbow trout (Oncorhynchus mykiss) hatch in inland streams and then swim downstream to forage in the Great Lakes (or the ocean, on the west coast) for 2-3 years. Winter-run steelhead are sexually mature and generally have a shorter run to their spawning grounds, whereas the summer-run steelhead are sexually immature when they leave the lakes or ocean and travel deeper inland. Actual spawning for either type happens in late winter or spring. These Pacific rainbow trout were introduced as immigrants from California to the Au Sable river around 1876 and after many generations are well established residents although state-managed hatchery programs supplement the existing wild fish.

Steelhead provide a loose metaphor for medical professionalism. We train our successors in the streams of academic medical centers and on maturity they go off to do their thing in the wide world. Toward the end of their careers many of them want to reconcile with their origins and travel back upstream to check out their starting points. Forgive me for stretching this analogy, but I do want to put in a plug for our Nesbit alumni, former students, and friends of the department to come back for one of our academic events, particularly in the next two years as we gear up to celebrate the Centennial of Urology at Michigan in 2019-2020.

 

Five.

Fish and urologists. Fish have twofold purposes. Primarily they pass along their DNA to their successors and secondarily they serve the larger planetary ecosystem. The optimal life span of a steelhead allows 4-6 years for one or more foraging careers in the wide world, although some Pacific steelhead live as long as 11 years and grow to 55 pounds and 45 inches, according to the National Oceanic and Atmospheric Administration (NOAA) Fisheries website.

Medical professionals have a fundamental purpose of caring for their fellow creatures, motivated by genetically crafted mirror-imaging that produced the essential human phenotypes of kindness and empathy. Secondarily, healthcare people serve their ecosystem by educating their successors and expanding the armamentarium of knowledge and technology. The career of a urologist is 40 years, give or take a decade, foraging in the real world of clinical medicine. While steelhead must adapt to gradual warming of the oceans, urologists need to adapt to rapid changes in knowledge, technology, and regulatory matters. Technology and market forces are driving changes in urologic practice at least as much as scientific evidence, leaving practitioners and patients sometimes uncertain of what treatment fits best.

 

Six.

Urologists are skilled in techniques and technology to solve urological problems but, no less than any other physicians, urologists also offer their personalities, opinions, and reassurances to patients throughout interactions that are bundled under the unfortunate label “encounters” in today’s workplaces and medical records. The language and demeanor experienced by patients often are just as meaningful to them as any treatment or technology. Indeed, the non-technical aspects of the encounter may impact the patient more than any specific medical service. This is a prime difference between the professional and a commodity natures of health care. People, as patients, treasure the right human touch.

The essential deliverable of our department is kind and excellent patient care, thoroughly integrated with education and innovation at all levels. This is not just our priority, but the priority of Michigan Medicine. Below is another picture I found from 2007 showing a faculty member and two residents who exemplified that essential deliverable back then and do so today in their new locations: Gary Faerber, now at the University of Utah; Emilie Johnson, faculty at Lurie Children’s Hospital and Northwestern Medical School; and Kathy Kiernan on the right, faculty at the University of Washington and its children’s hospital.

The human touch is also conveyed by words. A recent Viewpoint in JAMA by Arthur Barsky of the Department of Psychiatry at Brigham and Women’s Hospital is worth reading. [Barsky. JAMA. 318:2425, 2017]. The title sums it up: The iatrogenic potential of the physician’s words. Barsky invokes viscerosomatic amplification to explain how a physician can affect through words and attitude. (As is usual on these pages, we use physician as a synonym for healthcare provider.) Techniques and technology are unquestionably at the core of urologic practice, but the art of clinical practice is far more than its tools and treatments. Kindness, words, and professional touch are no less essential.

 

Seven.

Expectation. Human brains add further dimensions to medical treatments, with the matter of expectation. Every treatment carries the possibilities of real benefit or harm, but another two-edged sword exists in our capacity for imagination, something we cannot easily turn off. We may readily imagine benefit even when no physical or physiologic benefit can be explained (the placebo effect) or we may imagine elements of harm (nocebo).

Placebo and nocebo effects confound medical treatments when a therapy (legitimate or bogus, scientifically-validated or apocryphal) has a more positive or more negative effect than it rationally should have. This reflects changes in psychobiology rather than changes in physiology, pharmacokinetics, or other factors that are directly measurable or attributable to the treatment.

Nocebo, the evil twin to the placebo, is a term coined in 1961 by WP Kennedy. [Kennedy WP. Med World. 1961; 95:203, 2013.] The evil twin metaphor came from Michael Glick in an editorial in the Journal of the American Dental Association. [Glick M. Placebo and its evil twin, nocebo. JADA.2016; 147:227.] The nocebo effect occurs when negative expectation of therapy exacerbates the negative effect that the treatment rationally would cause. For some patients a given therapy, let’s say a radical prostatectomy, in addition to successfully removing a malignancy (from which direct harm might have been years away) with minimal detriment to related anatomic structures, might produce a sense of relief that carries with it additional placebo effect. For other patients a nocebo effect negatively magnifies the overall therapeutic experience and collateral damage of any attendant detriments. Every patient responds individually and idiosyncratically to an expectation and to a treatment. These phenomena, placebo and nocebo, should be anticipated for almost everything we offer in healthcare, and to the extent that we understand these possibilities and prepare patients and their families for them, we will improve the patient experience. This is one of the myriad ways that complex health care cannot be easily managed as a commodity or by artificial intelligence.

 

Eight.

As scientific medicine emerged in the 19th century it consolidated into subspecialty medicine in the 20th century and anatomic, physiologic, and microbial determinants became the focal points of healthcare. Cognitive and social factors were “marginalia” of most patient encounters. Now, in the 21st century it is clear that cognitive and social factors are equally important parts of everyone’s healthcare needs. Our profession and its business are no longer accurately described as the matter of “medical care”, but rather the matter of health care.

A prescription for a treatment or an operative procedure may be based upon symptoms and observations as entered into checklists and databases. Emotional responses and social determinants are not so easily factored in electronic medical records, particularly within the constraints of time-constrained encounters. Watson and other artificial intelligence systems are working their way into examining rooms, bedsides, and operating theaters, but these are not as effective in sensing the co-morbidities, social determinants, and other “marginalia” of the human condition, as is an attentive and kind human being. Artificial intelligence engenders great enthusiasm, but humanity should never surrender its ultimate agency to algorithms created by a self-empowered cadre of programmers.

 

Nine.

Considering gaps last month, including astronomical gaps, calendar gaps, and geological gaps, we saved an important one to mention now. A gender gap has long been present in the field of urology, although Michigan more than most other training programs began to change that imbalance, starting with Carol Bennett, who trained under Jack Lapides and was Michigan urology’s first woman graduate. Carol is now on the faculty at UCLA. In her era of training women in urology were rare. Today the situation is quite different and at Michigan we have had residency classes where women outnumber men three to one. Other years we have returned to 100% men and some year soon we could as easily have all women. In our selection process, we don’t aim for an optical effect, but rather try to pick the best talents and fits for our department from the yearly applicant cohort. Ultimately, individuals from the candidate pool make their selections when they rank the programs. [Below: Peter Knapp, Nesbit 1985 and Carol Bennett, Nesbit 1983.]

Women graduates from the University of Michigan Medical School and women trainees from our urology training program (all are considered Nesbit Alumni) are making significant impact in the world of urology, academically and in the private sector. Below you see a dinner at the recent annual meeting of the Society of Women in Urology. From the left: Cara Cimmino UMMS and faculty at Emory, Priyanka Gupta UM urology faculty, Allison (Lake) Christie Nesbit graduate and urologist in Tennessee, Miriam Hadj-Moussa Nesbit graduate and UM urology faculty, Lindsey Herrel Nesbit graduate and UM urology faculty, Akanksha Mehta faculty at Emory, Amy Luckenbaugh UM resident, and Annie Darves-Bornoz resident at Vanderbilt.)

 

Ten.

John Hall, Nesbit Alumnus 1970, wrote recently and gave me permission to give his note wider distribution here in Matula Thoughts. I came to know John after I came to Ann Arbor, largely through his high-quality practice, a sliver of which I appreciated through his pediatric referrals, as well as his local care of people I knew in the Traverse City area where he worked. Letters like his are one of the great pleasures of mine with What’s New our monthly email and it’s sibling Matula Thoughts, the web version. As we get closer to our Centennial and to reformulating our departmental history, his recollections, and perhaps yours as well, will be important to us.
From John:

“Hi Dave, I was just reading your letter of December 21, 2017. It made me think of the 5-6 doctors who staffed Urology during my training. Your staff will be limited to how many names you can put in the letterhead margin. It’s like how many doctors can fit on the head of a pin.

I finished my training in 1970, Urology 50. By 2020, Urology 100, if I’m still kicking I will be one of the few to span the history of the department. I started my contact with Urology as a student and served as a “nurse” in the Urology dialysis center. I took the vitals as the residents stirred new electrolytes into the Kolff Twin Coil Baths. As a result, I knew many of the residents from the fifties and sixties. Also, since I was appointed to residency by Dr. Nesbit, I met many of his trainees who now directed new urology departments, when they returned to AA [as visiting professors or guests], I also once met Dr. Huggins.

Dr. Nesbit retired in 1967, six months into my residency. So my group became Lapides 1. I’m not going to measure up to your knowledge of urologic history, but I am willing to provide my perspective of Michigan Urology to the Centennial Committee. Please let me know if I could provide some value to the process. Please keep writing Matula Thoughts, the highlight of my month! … John.”

Thank you, John and yes, please continue your perspectives! Much is contained in John’s brief note: the idea of 100 years of urology in AA, the imprinting of students, the Kolff “artificial kidney”,  Nesbit alum and Nobel Prize winner Charles Huggins, and the long list of chairmen Nesbit trained. Overstated only is the disproportion of historical knowledge between me and John – he knows vastly more about that midpoint in Michigan’s urologic story and I hope we can get as much as possible in print for you and others to understand our perspectives.

Since that note, John sent me a copy of his book “I’d Rather Be Sailing” and I expect to go through it and decorate it thoroughly with my own marginalia. As we reconstruct the 100-year story of Michigan Urology it will be the personal marginalia of alumni such as John Hall that provide the context, color, and personalities to illuminate the names and dates of our narrative.

 

With a few weeks until Spring, 2018, best wishes from David Bloom and Michigan Urology.

January 5, 2018

DAB What’s New Jan 5, 2018

New year thoughts
3899 words

 

One.
Dripping icicles are picturesque winter images, although this week’s massive winter storm, Grayson, extending from Florida to Maine disrupted any nostalgic thoughts of snow and ice. The icicles photographed from my study window (above) echo the pendant spikes painted by Pieter Bruegel the Elder in Massacre of the Innocents circa 1565-67.

Bruegel’s icicles (above) look charming enough, until you view the grim larger work (below – original at Queens Gallery, British Royal Collection). One broken icicle is falling in response to men kicking in an adjacent door. The actual painting has a complex history of paint-overs transforming it from grisly slaughter of babies to the plundering of a village.

So, too, the larger work of today’s climate gives the icicle a chilling perspective, as it brings to mind the Greenland Glaciers, among other melting ice forms.

Although water’s origin on earth remains controversial, water is one of the key things astronomers seek when evaluating other planets that could initiate or sustain life. Water, so central to life, is a synonym in medicine for urine, amniotic fluid, ventricular fluid, lymphatic fluid, and other waters of our bodies. Frozen water in the form of sea ice and glaciers, more or less stable for the past 10,000 years, is melting at an extraordinary rate, threatening the delicate balance of planetary life.

A startling image from the U.S. Geological Survey (USGS) website shows how little the Earth’s water  compares to the volume of the earth itself. Paraphrasing from the USGS website:

The three blue spheres below represent relative volumes of Earth’s water in comparison to the size of the Earth. In comparison to the volume of the globe, the amount of planetary water is small; oceans account for only a thin veneer of water on the surface.

The largest blue sphere represents all of Earth’s water. Its diameter is 860 miles (the distance from Salt Lake City, Utah, to Topeka, Kansas) and has a volume of about 332,500,000 cubic miles (1,386,000,000 cubic kilometers). This includes all of the water in the oceans, ice caps, lakes, rivers, groundwater, atmospheric water, and even the water in living creatures.
The blue sphere over Kentucky represents the world’s liquid fresh water (groundwater, lakes, swamp water, and rivers). The volume comes to about 2,551,100 mi3 (10,633,450 km3), of which 99 percent is groundwater, much of which is not easily accessible. The diameter of this sphere is about 169.5 miles (272.8 kilometers).
The tiny bubble over Atlanta, Georgia represents fresh water in all the lakes and rivers on the planet. Most water that life on earth needs every day comes from these surface-water sources. The volume of this sphere is about 22,339 mi3 (93,113 km3). The diameter of this sphere is about 34.9 miles (56.2 kilometers). By comparison, Lake Michigan looks way bigger than this sphere, but you have to imagine the bubble is almost 35 miles high—whereas the average depth of Lake Michigan is less than 300 feet (91 meters). [With permission, Woods Hole Oceanographic Institute. Credit: Howard Perlman USGS, globe illustration Jack Cook, Copyright Adam Nieman.]

 

Two.

Dividing human moments into calendar years, we “start fresh” each new year with renewed opportunities to explore the world intellectually and geographically. The globe of the Earth is a tool and metaphor for human exploration as well as a visual remonstration to the “Flat Earth Society.” The globes shown above are displayed in a hallway in the Harlan Hatcher Library. If you work here at the University of Michigan or even if you don’t, but happen to be in Ann Arbor and want to explore the campus, “check it out,” when you have time.

Interrogation of the moment has been a uniquely biologic phenomenon. A rock is not aware of its environment even though it is affected by it. The rock cannot consider the things around it nor empathize with whatever it may roll down upon. Our human predecessors well before Aristotle thought about matters like this (they called them metaphysical) and passed these thoughts to their successors. When language and technology permitted, these metaphysical considerations were made somewhat durable in writing.

Biology shows that humans are not unique in this capacity of interrogation, even microorganisms react and respond to their microenvironments and communicate among themselves. All biologic creatures interrogate their moments, but our species has learned to do this very well and pass along observations for future generations to consider. We do this unwittingly by epigenetic management of our DNA and purposefully through our ideas, our culture, our objects, our written language, and our sports, as seen below in interrogation of the moment by Michigan quarterback John O’Korn during Ohio State game. [From Sincock Suite. November 25, 2017. Sony 24-240 FE]

Standing at the threshold of coexistence with systems built around artificial intelligence, we are now affected by their ability to interrogate us and to increasing degrees we are transferring many decision-making powers of our human agency to these systems.

 

Three.
Imagined Expectations. It may seem premature in this calendar year to mention Abraham Lincoln. Most any month but January provides a good excuse to think about Lincoln. His birthday was in February, 1819 and next month it will be the 199th anniversary. He died in April, 1865. His most famous speech, The Gettysburg Address, was in November, 1863. What brings him to my mind just now, however, is the starting sentence of that speech on November 19: “Fourscore and seven years ago our fathers brought forth on this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.”

Lincoln’s remarkable use of the phrase “fourscore and seven” converted a mundane metric of 87 into a poetic measure of time. He was referring to the age of our nation, but that measure of time also equates to one very fortunate human life span, although for Lincoln’s time, in the antebellum South of the U.S., the average life expectation for a white male was 38.3 and 40.5 for a white female. I couldn’t find equivalent data for other men and women of color until 1900 when it was 32.5 for males and 35 for women. All such data is a suspect approximation for reality, and means little to the particular story of any individual man or woman.

My point here, admittedly a bit strained, is that our limited personal solar cycles provide a single human the opportunity to interrogate one’s times and world, so as to navigate it well and possibly to improve it for successors. Borrowing from Lincoln, three score and ten is a more typical fortunate expectation for most of us, given the personal good luck of health, security, and opportunity that communities and governments should provide. Four score and seven is a very optimistic expectation, and for that the luck and security of health is essential.

An individual human’s expiration date hinges on genetics, luck, opportunity, choices, and the general randomness of events. For me, as a youngster growing up in the rhetoric of the Korean War, McCarthyism politics, nuclear war anxiety, air-raid drills at school, and the personal insecurity of one’s own potential and relevance, the mere idea of surviving into the 21st century seemed fanciful. Yet here we are in 2018.

 

Four.

Dee Fenner, the new chair of the OB GYN Department, is a perfect choice for Michigan Medicine (seen above with husband Charlie at autumn DEI reception). Dee is a world-renown gynecologist, a superb educator, and a first-rate administrator who has gained the respect of her colleagues at Michigan in her numerous administrative responsibilities. She also holds a joint appointment with Urology, along with 3 other members of her team. Since the days when Ed McGuire was Section Head of Urology, our departments have had a close relationship. I well remember my earliest days here when Ed and John DeLancey had a combined pelvic floor dysfunction clinic on Saturdays. Dee and I met shortly before she returned to Michigan. We were in Paris at a WHO Consensus Conference in 2001 and by coincidence found ourselves in a pen shop as the only Americans.

Words of praise are due for Tim Johnson, the outgoing chair of OB GYN and a friend of urology for the 24 years of his successive terms. Few figures in his field have generated equal respect for leadership in national and international OB GYN. His work in Ghana is legendary. Tim brought his department at Michigan into the 21st century with superb clinical divisions, excellent faculty, coveted educational programs, and worthy contributions to the knowledge of his field. Tim has been a stalwart force in the domain of women’s rights. His sense of the centrality of the essential deliverable of kind and excellent patient-centered care (if you permit me some repetitiveness) has made him a terrific colleague. His department consistently and superbly delivers its products (forgive the relevant pun).

Sad news on the recent passing of Rudi Ansbacher, emeritus professor of OB GYN and a remarkable colleague.

 

Five.
Matula Thoughts, recap. Throughout the millennia of human history clues to predict the future have been highly prized, especially so when a given future is related to health. Entrepreneurial “healers” utilized external cues from the heavens, weather, tea leaves, or playing cards to prognosticate outcomes, although the logic of using physical evidence from patients or their byproducts was evident to early practitioners. Like most other mammals, humans share the trait of personal interest in their urine, and are particularly attentive when it is abnormal during illness. Hippocratic writings documented uroscopy, as examination of urine came to be called 2500 years ago, and over the ensuing millennia the practice attained imaginative prognostications as healers examined the gross characteristics of urine in flasks called matulas to speculate on the course of an illness. The visual image of a “piss prophet” gazing at a matula served as a main symbol of physicians until only about 200 years ago when the stethoscope replaced the flask as medicine’s badge of office.

We began this electronic journal nearly 18 years ago with a respectful tip of the matula to the essayist Michel Eyquem de Montaigne who began his eclectic personal observations around 1572 at 39 years of age. That was a turbulent time, notable in Europe for the sieges of Sancerre and Haarlem, in South America for the fall of the last independent remnant of the Inca Empire, and in the heavens for the first observation of Supernova SN 1572, that Tycho Brahe gave as evidence that stars are changeable. Montaigne was likely unaware of most big events of that year, but he was certainly acquainted with physicians and matulas, given that his father purportedly died of urinary stone disease and Montaigne himself began to suffer from them in 1578.

What impulses compel us humans to foist our personal observations and thoughts on our fellows may someday be revealed through the matula’s diagnostic successors such as the MRI and other marvels of imagination, but there is no arguing that those impulses are strong and prevalent. This monthly newsletter started in Allen Lichter’s dean’s office in 2000 as a way to interact with those among our faculty willing to consider some thoughts from a colleague. Admittedly, I wrote this column called What’s New as much for myself as any potential readers, but it became a pleasant habit to send out the first Friday of each month. Becoming chair of the University of Michigan Urology Department in 2007 the monthly column transitioned to our faculty, residents, staff, alumni, and friends. What’s New has served us well, connecting us to many of our intended audience and beyond. Some recipients kindly forward What’s New to their friends, although the extent of that particular reach is mostly unknown except for occasional readers who have contacted or commented to me as a result.

 

Six.
We began a parallel version of What’s New in March, 2013, on a website labelled Matula Thoughts. This version allows us to archive the monthly columns, thereby minimizing duplication and providing the unexpected voyeuristic capability of showing the numbers and distribution of web-version readers. Likely only some of them read this carefully, while most probably glance or sprint through it. Nonetheless, the surprising numbers and distribution are evidence of the internet’s ability to connect the world. [Screenshot below – 2017 statistics page of Matula Thoughts.]

Matula Thoughts, had over 2,300 views last year, ranging from single viewers in 24 countries, 2 viewers in 6 countries, and 3 in 11 countries. Forty-one countries had 4-85 views and the US had 2364 views as of mid-December, the map showing stats for the readership in 11.5 months of 2017. It has been enjoyable to hear from, or run into, the occasional reader of the web version.

With a new chair of the Urology Department, presumably this calendar year, What’s New may be continued or another vehicle of departmental communication may be utilized, but in either case Matula Thoughts will remain in its online form (matulathoughts.org) as long as I’m able and a readership exists. These spaces will continue to be filled by matters that catch my attention and may interest some readers.

 

Seven.
Each year has a certain cadence, whether calendar, academic, or fiscal for each of the countless social and business organizations around the globe. The success of a particular person, novice or experienced citizen, in navigating the year is partly contingent on that person’s understanding of the rhythms of work and expectations of their relevant organizations.

In a clinical surgical department, the 24/7 expectations of stakeholders set the central cadence for our essential deliverable – kind and excellent patient care. The stakeholders are patients, families, trainees, staff, faculty, referring health care providers, colleagues in other departments, and the community. Around this we build our educational conferences, work schedules, training cycles, maintenance of professional certification, peer review cycles, promotional steps, reappointment sequences, and social events such as our Holiday Party that last month hosted 400 people and 115 children who had encounters and gifts from Santa. As our department has grown large this event seems to have become increasingly treasured and is the single occasion to aggregate the greater part of our complex team.

The cadence of the new chair search will capture our attention. In the case of Dee Fenner and the OB Gyn Department the process took around 6 months. Dee was the natural choice and had passed up a number of other prestigious offers from other institutions in order to remain at Michigan. At this point she is the only other chair here to have a joint appointment with our department.

 

Eight.
Breakthrough of the year. Science, the AAAS journal, began a feature called Molecule of the Year in 1989, following Time Magazine’s Man of the Year that had started in 1927. Wikipedia relates that Time’s cover was originally a response to its embarrassment earlier that year in failing to put Charles Lindbergh on the cover following his trans-Atlantic flight. As the Man of the Year expanded to including all persons, as well as groups (in 1960 it was U.S. Scientists), ideas, or objects, so too did the Molecule of the Year to become the Breakthrough of the Year.

Science named the observation of cosmic convergence, a violent merger of two neutron stars on 17 August as the scientific breakthrough of 2017. Runners-up included cryo-electron microscopy observations on organic molecular function, thermoluminescence dating of early human roots, pinpoint gene editing techniques, preprint sharing in life sciences, FDA approval for checkpoint inhibitors, discovery of a new living species of Hominidae (the Pongo tapanuliensis orangutan), recovery of 2.7 million-year-old ice cores that contain ancient atmosphere (with CO2 levels under 300 ppm), and successful gene therapy for spinal muscular atrophy 1. Once again, biology dominated the main scientific achievements of the year.

 

Nine.

Disclaimer. Because of a few skunks in academic medicine, speakers at nearly every medical presentation around the world declare absence, or occasionally presence, of “conflict of interests.” Mostly these are silly declarations, and effective skunks either lie or mislead audiences with their declarations. It is easy to mislead others, because all social transactions, especially those in health care and in academia, are built on trust.

The necessary velocity and fluidity in science and medicine preclude extensive authentication and verification in real time. For example, when a colleague tells you that a serum creatinine is 0.8, you accept that as fact. Mistakes may happen in our workplaces, but they should sharpen our attention to truth and not let false facts become a way of life. Once, however, deliberate lies or plagiarism are revealed trust should never easily be restored. The cutting and pasting that has become so easy, indeed almost necessary, in the modern electronic medical record allows a very seamless slip from mistake to deceit, once a clinician starts to lose the sense of individuality of patients. When a physician loses that appreciation of the uniqueness of a patient, a history and physical for, let’s say a boy with undescended testicle, can be “generalizable.” Checking off a few boxes, or even cutting and pasting an entire H&P, is certainly more efficient than asking questions, observing the patient and family, and examining the child. This is akin to Paul Simon’s cynical song, The Myth of Fingerprints.

Another associated, yet perhaps minor, gripe I have with the EHR occurs in the operating room, when at the end of a procedure in the well-intended, but tedious “time out” I am asked to describe the blood loss. My claim of “minimal” is always rejected because the computer only allows a number. In many cases a tiny bit of red can be seen, but is it 0.5 ml or 5.0 ml? It is somewhere in that range, but unmeasurable, insignificant, and inconsequential. When I am asked to fabricate a number, my mind rebels and when I do come up with a number it feels more like a lie than a guess.

Anyway, with the start of a new calendar year I thought a disclaimer would be useful. Therefore, let me state that I seem to have no conflict of interest or conflict of commitment that would steer the comments in What’s New/Matula Thoughts to any drug, product, political party, or ideology outside of belief in liberal democracy (life, liberty, and the pursuit of happiness under representational government), public education, planetary conservation, social justice, and The University of Michigan. The thoughts herein, unless authorship is otherwise specified, represent mine alone. I don’t necessarily speak for our Department of Urology, Michigan Medicine, The University of Michigan, the State of Michigan, the United States, or the United Nations.

Hoping you are comfortable with these statements, I invite you to peruse, delete, comment upon, or forward What’s New (the email version) or Matula Thoughts (the web-site version) this new year of 2018. What’s New is a hint that we offer some news from our academic department and health center. Matula Thoughts is a term that hinges on an ancient symbol of the medical profession that was a transparent flask used to examine urine, one of the few clues to disease that ancient caregivers had available. The matula was replaced by Laennec’s invention of the stethoscope in 1816 in Paris, but both tools reinforce the threatened idea that physicians should look at and listen to their patients.

 

Ten.

 

The new year, 2018, began with Michigan’s appearance at the Outback Bowl in Florida four days ago and many red moustaches and haircuts in support of the Chad Tough Campaign for brain tumor research.

Alon Weizer is Acting Chair of our department for the next three months. This cycling of our associate chairs has been healthy for the department and for me. During this time I’ll be working on the UMMG Bylaws, helping re-activate our Michigan PAC, laying out plans for our centennial, and continuing some development efforts, and remaining active with the Hamilton Community Health Center and its board.

Some people have queried the administrative structure of our department. Our basic backbone is the Senior Clinical Management team, composed of our division heads, our residency program director, and our peer-review quality officer. The associate chairs have responsibilities that transcend divisions, for example the research portfolio, faculty affairs, operating room distribution, in-patient clinical operations, and ambulatory care management. Our ultimate responsibility, day-in and day-out, is the essential deliverable of kind and excellent patient care. Michigan Medicine, our other departments, the community, referring physicians, and the University of Michigan depend on our ability to do this very well. This essential deliverable is also our primary financial engine, as we defend and expand our markets. It should go without saying that these markets are clinical, educational, and academic markets.

We have been fortunate over the past 2 decades of Jim Montie’s and my terms in delivering our particular essential deliverable and in defending and expanding our markets. Few could find major deficits in those regards, as our external review by Mark Litwin, Ed Sabanegh, and Bradley Leibovich pointed out recently. However, the waters ahead will be turbulent and we will need a steady and resourceful hand who enjoys the support of our faculty.

This winter, a search committee convened by our deans is in the process of finding candidates for leadership for our department. Having experienced one disastrous change of leadership for Urology after Ed McGuire left us for Texas in 1992, we are aware of the risks of change, but our deans and the search committee at hand give us confidence in a good outcome. With superb division heads and associate chairs in place we have a very strong and deep bench. If there is a better external candidate on the planet, good for us, but it would be hard to beat our bench.

I don’t think I’ve left too many administrative problems for Alon, after all we have finished our main work of the cycles of reconciliation of FY 17 and planning for FY 19, on-boarding of new faculty, academic promotions, and residency recruitment. Alon will oversee the daily operations and occasional crises inherent to any business with several hundred employees, clinics at 16 sites, surgical teams at 9 locations, training of 28 residents and fellows, six separate investigative teams, etc.

Our new relationship with West Shore Urology in Muskegon has energized us and created a new reach to the west side of the state. The growing relationship with Mid-Michigan and with Metro Hospital also offer great opportunities. Our efforts with the Hamilton Community Health Network in Flint continue as well, and I’m especially grateful to members of our urology department and a few other UM departments who have participated in this important connection.

A busy year and a half lies ahead. In February we should hear the names of the new resident trainees to join our department. Our Departmental Retreat, April 14, will take stock of where we stand and where we are headed. The Teeter Symposium, May 4, will survey our work with bladder cancer. The Nesbit Alumni Reception at the AUA will be held on Sunday May 20 in San Francisco. During the Art Fair Season the Chang Lecture on Art and Medicine July 19 will inaugurate a new residency training season. The next day Hadley Wood of the Cleveland Clinic and Rosalia Misseri of Riley Children’s Hospital in Indianapolis will be the Duckett and Lapides Lecturers. The biennial Dow Health Services Research Symposium will take place September 13 and 14. Our own alumnus, Toby Chai of Yale University, will be Nesbit Alumni Visiting Professor September 20-22. The Montie Uro-Oncology Lecture is planned for early 2019, and later that year we will begin our Urology Centennial Celebrations to transition into the second century of urology at the University of Michigan, under improved new management, by then.

 

Thank you and Happy New Year from the Department of Urology of the University of Michigan.

 

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