Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

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

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

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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

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


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


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

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

2017 is here

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

 

grand-rounds

One.

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

galens

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

holiday-party

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

fac-mtg

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

 

 

Two.

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

washington

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

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

Washington set the tone in the opening sentences.

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

The conclusion was optimistic.

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

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

 

 

Three.

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

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

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

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

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

tim-johnson

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

 

 

Four.

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

runge-cantor

 

 

Five.

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

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

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

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

 

 

Six.

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

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

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

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

 

 

Seven.

hamilton

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

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

ham-board

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

mike-clarence

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

ben-team

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

 

 

Eight.

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

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

orson_welles_war_of_the_worlds_1938

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

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

 

 

Nine.

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

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

fifth

————————————————–

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

stats-mid-dec

[Above: MatulaThoughts analytics in mid-December]

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

 

 

Ten.

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

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

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

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

hew-seal

[Above HEW seal; below HHS seal]

hhs-seal

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

 

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

Matula Thoughts December 2, 2016

Politics, nutcrackers, and earthly delights
3799 words

One.

election-2016-copy

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

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

herblock1950

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

castro

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

 

 

Two.

colors

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

baa

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

supermoon

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

first-quarter

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

snowy-4th

um-20-iu-10

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

 

 

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

el_jardin_de_las_delicias_de_el_bosco-1

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

van-leyden

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

 

 

Four.

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

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

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

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

 

 

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

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

lange

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

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

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

 

 

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

 

 

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

peterson-tim

 

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

 

 

Eight.

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

nutcracker

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

 

 

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

house-of-cards

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

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

 

 

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

repub-pres

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

political-promises-copy

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

 

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

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

Castling

DAB Matula Thoughts Nov 4, 2016

 

Matula Thoughts Logo2

3975 words

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

huron

One.  

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

silo

 

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

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

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

 

 

Two.  

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

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

dsc03595

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

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

 

 

Three.          

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

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

 

 

Four.                 

bruxelles_manneken_pis        

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

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

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

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

“Sirrah, What says the doctor to my water?

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

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

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

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

the-wayfarer-large

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

bosch-detail

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

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

 

Five.              

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

castmove

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

alaska

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

 

 

Six.

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

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

 

 

Seven.

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

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

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

 

 

Eight.

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

 

 

Nine.

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

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

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

 

 

Ten.              

jiffy-silos

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

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

wh-balcony

[Next occupant?]

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

leaves

[October driveway]

 

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

April First, 2016

DAB What’s New April 1, 2016

Hearts & hoaxes, questions & bells

[matulathoughts.org]

(4073 words)

 

One.  Noteworthy births.

508px-William_Harvey_2

The first of April  has a small share of notable birthdays for physicians, scientists, and others who impacted the human condition. A name that rings a bell is William Harvey (1578) shown above. This English physician produced the first accurate description of the function of the heart and  circulation of the blood in his book, Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus [Painting attributed to Daniel Mytens, 1627. National Portrait Gallery London] Predecessors back to the time of Galen had gotten the physiology wrong, but Harvey was forgiving in his discovery, telling students: “Not to praise or dispraise other anatomists, for all did well, and there was some excuse even for those who are in error.” French mathematician Marie-Sophie Germain (April 1, 1776) produced pioneering work in elasticity theory and Fermat’s Last Theorem. Bismarck (1815) and Rachmaninoff (1873) came along as April firsters in the 19th century. Joseph Murray (April 1, 1919 – November 26, 2012) was a plastic surgeon and close friend of my old professor at UCLA, Willard Goodwin. When I was a resident I naively thought Joe was somewhat out of his league in his yearly travel group of old friends that included Goodwin and Robert McNamara, until Joe got the Nobel Prize for his work with renal transplantation.

DAB Murray copy

[Above: Joe Murray visiting UM & young faculty member out of his league. Below: 2 legendary Michigan coaches – Steve Fisher & Bo Schembechler]

Bo & Fish copy

Bo Schembechler (April 1, 1929 – November 17, 2006) is, of course, legendary for us at the University of Michigan. More controversial is Abdul Qadeer Khan (April 1, 1936), a Pakistani physicist who disseminated nuclear weaponry to rogue nations of the world.

Unlisted so far in the Wikipedia tallies for April first birthdays is Paul Kalanithi (April 1, 1977 – March 9, 2015), author of a current best-seller When Breath Becomes Air. Finishing residency in neurosurgery at Stanford the author discovered he had metastatic lung cancer. The book has a simple structure: a prologue, Part One In perfect health I began, Part II Cease not till death, and then an epilogue by his wife Lucy.

We each quietly contemplate deeply personal questions related to what might be described as the meaning of life, but circumstances gave Kalanithi urgency to come to some resolution. He exposes his thoughts with literacy and without self-pity. The meaning of life he discovered for himself lay in what he called human relationality. The context of one’s life is what matters, he believed, and it is from relationships with others that we derive meaning. Physicians and other health care providers should have a head start in the personal search for meaning, if you accept Kalanithi’s view, although many don’t understand that advantage. A spiritual person at the end of life may derive comfort from a religious faith or from a faith in the order of the universe and, perhaps, a reassuring sense of the circle of life as the Lion King said. On the other hand a cynical person might claim that faith is only a hoax we play upon ourselves and that each of us should grab whatever we can before our individual turns at life are over. No one can genuinely tell anyone else what the truth actually might be, we each must figure it out for ourselves. That individual worldview is what makes each of us what we are, each of our presidential candidates what he or she is, what the pope is, what El Chapo is, and it made Paul Kalanithi what he was.

 

Two.              Happy New Year.

For reasons lost in the deep recesses of history, the first of April has become a day for harmless pranks and hoaxes. April was the first full month of the new calendar year until only a few centuries ago. In Europe and during the Middle Ages March 25 was considered New Year’s Day. Possibly the natural human bent for trickery consolidated around that yearly transition. Japan begins its new year on the first of April and for this reason Dr. Takahiro Osawa and his family now return to Sapporo after 2 productive years with us in Michigan. We will miss him.

Screen Shot 2016-03-18 at 10.48.00 PM

Taka tells me that April pranks are also a tradition in his country. April foolery has endured around the world since first alleged references in Chaucer’s Canterbury Tales in 1392.

Exactly 40 years ago (1 April 1976) during a BBC broadcast English Astronomer Patrick Moore predicted that a “Jovian-Plutonian gravitational effect” would cause a noticeable short-term reduction on Earth’s gravity. At 9:47 AM on that day (GMT), he announced, a momentary alignment of Pluto and Jupiter would decrease Earth’s gravity such that those who jumped into the air at that moment would experience a floating sensation. Soon thereafter, BBC received hundreds of calls from people who claimed to have had felt the effect. The story was revealed to be a hoax, but Moore was a believable prankster and 4 years later he co-authored a totally factual book on Pluto with Clyde Tombaugh, who had discovered the dwarf planet in 1930.

Pluto

[Pluto, NASA image. North polar region at top. Notice the large bright Tombaugh Regio, nicknamed The Heart, lower right of center.]

The idea of fluctuating gravitational fields was prominent in Kurt Vonnegut’s book Slapstick (published in 1976, the same year as Moore’s hoax) and if you notice cyclic patterns in human behavior you might find some validity in Vonnegut’s satirical hypothesis. A prediction 100 years ago along a similar line was made by Albert Einstein. Stemming from his theory of general relativity he predicted the idea of gravitational waves that could transport energy in the form of gravitational radiation. Hypothesis rather than hoax, it took a full century to prove this idea. On February 11, 2016 the LIGO and VIRGO Collaboratives announced discovery of a gravitational wave from a pair of black holes that spun into each other 1.3 billion light years away. The wave passed by the Earth this past September 14 when it was noticed initially by Marco Drago, a 33-year old Italian Physicist in his office at the Max Planck Institute in Hanover, Germany. [A. Cho. Science. 351:797, 2016] Teams and collaborations of thousands of people spent over 100 years seeking a gravitational wave, although Drago was the first to notice the anomalous signal, and even then his first thought was that it was a glitch or a trick.

Our ability to sort out truth from myth, stories, hypotheses, hoaxes, science fiction, propaganda, and blatant deceit is constantly being tested. April Fools’ Day offers a playful “reset button.”

 

Three.           The heavy human footprint.

glacier

[USGS Water Science School]

Winter is officially over and while we did have some cold days, it wasn’t quite as cold or snowy as my memory tells me it used to be. Of course all things change and many of them cycle, whether sunspots, seasons, or climate. It is no hoax, though, that the Earth is in a warming spell and that anthropomorphic effects on the planet are driving that and other detrimental changes. Curiously, large swaths of the population, including many elected leaders in our nation, deny the fact of significant environmental change due to human influence.

Earth, with a volume of 2.6 x 1011 cubic miles and a mass of 1.3 x 1025 pounds, is the densest planet in the Solar System with a mean density of 0.2 pounds/cubic inch (5.5 grams per cubic centimeter). While the origin of planetary water is still unknown and it seems so vast, its 3.3 x 109 cubic miles represents only 0.0013% of the earth’s volume, merely a thin wet veneer over part of Earth’s surface. (1 cubic mile = 1.1 trillion gallons)

global-water-volume-fresh

The image above comes from the USGS website (Water Science School). The big blue sphere represents all of earth’s water, the smaller sphere over Kentucky represents total fresh water, and the tiny bubble over Atlanta estimates the fresh surface water in lakes and rivers – this being what most of us 7 billion earthlings have available for drinking or washing. [Credit: Howard Perlman, USGS; globe illustration by Jack Cook, Woods Hole Oceanographic Institution © Adam Nieman.] Ice caps, glaciers, and permanent snow account for 5,773,000 cubic miles or a little less than 5.8 x 107 m3, or 17.6% of the earth’s total water.

During the last ice age, when Michigan was a mile deep below the Laurentide Ice Sheet, sea level was about 400 feet lower than it is today. At the other extreme, if all land and sea ice melted the ocean level would rise 70 meters or 230 feet. However you choose to describe it, the environment is changing rapidly and dangerously due to the heavy human footprint. This is no hoax or conspiracy.

A fragment of a speech from John F. Kennedy has resonated with me throughout my adult life: “For in the final analysis, our most basic common link is that we all inhabit this small planet. We all breathe the same air. We all cherish our children’s futures. And we are all mortal.” I recently asked my colleague and Kennedy scholar Kevin Loughlin for the origin of the quote and he immediately referenced Kennedy’s American University speech (titled A Strategy of Peace) on June 10, 1963. The president at the time had only a little more than 5 months to live. Flawed no more or less than most presidents or the rest of us, JFK did have inspiring intellect, clarity, and a way with words.

 

Four.             Ann Arbor notes.

In April 1985 my family and I had been in Ann Arbor for less than a year. Having accepted the job here as an associate professor (without tenure) I was still getting over the sting of finding myself demoted to assistant professor by the Medical School Executive Committee after arrival, but that’s another story. The Section of Urology was a terrific environment, Ed McGuire was a great boss, pediatric urology at Michigan was going well, and I loved my colleagues here in the medical school. The community was an excellent fit for Martha and our children, and we quickly found great friends. I distinctly remember the hoopla about a local restaurant, the Pretzel Bell, closing that April. This picture below from the old Ann Arbor News (used recently in Michigan Today) shows people lined up for an auction of Pretzel Bell memorabilia, necessitated by the IRS because of fraud related to employee withholding taxes. The article in Michigan Today by James Tobin explains that the original proprietors, John and Ralph Neelands, hung an old bell, said to have dated back to Civil War times, in the tavern. The story went that Fielding Yost had come to own the bell and gave it to the Neelands, after ringing it at Ferry Field. Ann Arbor has a rich German history and German university beer gardens traditionally featured two signs of hospitality – a bell to call in neighbors and a basket of pretzels.

pretzel bell Apr 1985

New ownership and management is resurrecting the Pretzel Bell and it should reopen soon to delight a new era of aficionados as well as old timers, for whom the name will ring a bell.

The University of Michigan has two bell towers (the original and the one on North Campus). The Bell Tower Hotel, across from the original, was the first place I stayed in Ann Arbor, when Ed McGuire invited me in 1983 to look at a pediatric urology job. A key predecessor of mine in the job had been Ed Tank, and his next-door neighbor back then, Dennis Dahlmann, now owns the hotel and has turned it into quite a gem. Ed Tank has retired in Portland, Oregon after a great career in our field. His excellent surgical results, the trainees he inspired, his academic productivity, and his organizational leadership constituted an extraordinary and admirable career. Ed’s successor in Portland, Steve Skoog, had been my resident at Walter Reed and is now a close friend and colleague. The coincidences in life are often beautiful.

Tank

[Above: Bloom & Tank. Below: Skoog and Dennis Peppas, former student of mine at USUHS, now pediatric urologist University of Texas, San Antonio]

Skoog copy 2

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[Below: Dennis Dahlmann & Bill Martin 2015]

Martin & Dahlmann

 

Five.              Metrics & mission.

A flawed general assumption in the business world is that an organization can be run, optimally, by cost-based accounting. If, in fact, all decisions could be based on numbers (metrics, as it is often said) then a good computer could replace all managers. Businesses, however, run based on people, relationships, and their stories at least as much as any numbers. Alon Weizer referred with irony to his excellent efforts at managing the Cancer Center ambulatory care unit (the largest in the UM Health System.): “it is easier to manage by metrics, rather than digging down into the stories behind them.” Of course we cannot ignore numbers and have to pay attention to them, they are a key part of our information intake, but they are hardly the only form of our intelligence. The idea of running a business from the central organizing principle of managerial cost-based accounting, rather than managing it according to mission, customer-based deliverables, and lean-centric employee engagement has been a damaging conceit of 20th century industry. Yet, paradoxically, just as managerial accounting is phasing out of forward-thinking businesses as the central operational paradigm, it has been colonizing the brains of health care system managers.

At our Urology Department Retreat 2 days ago, we grappled a bit with the importance of financial margin and the need to defend and expand our markets on one hand, but with the central values of mission and essential deliverable (kind and excellent patient-centered care) on the other hand.

David Spahlinger got us started at noon with an overview of our health system reorganization and urgent strategies. Marschall Runge closed the program around 6:30 with a lively Q & A session. Our health system and medical school are fortunate to have great top leadership at this point in time.

Screen Shot 2016-03-30 at 7.57.18 PM

[Retreat at Michigan Union]

 

Six.                 Bellmen.

We need leadership but too often find odd characters coming forward offering their services to take charge of our governments and more immediate organizations. Having studied and experienced great and poor leadership I’ve become somewhat cynical of those who have a pressing need to lead me. The cautionary tale of the Bellman is fitting. He was the captain of a ship’s crew in Lewis Carroll’s The Hunting of the Snark. His map of ocean (a blank paper) and contradictory navigational orders did not inspire his crew, but his rule of three (“What I tell you three times is true.”) helped lead them into strange territory. Sometimes it feels like this for those of us taking care of patients in large health care systems.

300px-Lewis_Carroll_-_Henry_Holiday_-_Hunting_of_the_Snark_-_Plate_1

[Cover of first edition Hunting of the Snark by Lewis Carroll 1876. Hendry Holiday, the illustrator born in 1839, died 15 April 1927]

Lewis Carroll, a mathematician, delighted in nonsense and intellectual pranks and he no doubt relished that irony. The beauty of math and science is their pursuit of verifiable truth. Bellmanism may work well in primitive societies, but it fails in free, just, and scientifically-educated societies. A modern bellman can say whatever he or she wants, as many times as they want, but for the rest of us to accept a claim, verification or proof is necessary. Trust but verify, is the adage we often hear. Scientists are rigorous about this way of thinking.

Thinking about statements and proofs, a long time ago Pythagoras proved that a2 + b2 = c2 for any right-angled triangle and most of us not only remember this is true, but we can actually prove it by a few examples or tests. A French lawyer and mathematician, Pierre de Fermat (1601-1655), asked himself: if a2 + b2 = c2 then can this be true for higher integers; in other words does a3 + b3 = c3  and is this equation generalizable for all powers? Fermat thought not and his conjecture was written in the margin note of a book in 1637, but his proof was apparently not recorded although he must have convinced himself that Pythagoras’s hypothesis only holds for special cases (like the number 2). For more than 350 years other mathematicians, including Marie-Sophie Germain, tried to figure it out, but failed until Andrew Wiles successfully proved Fermat’s conjecture in 1994.

Medical practice aspires to evidence and logic over Bellmanism. Nevertheless, much of what we do has to find a balance within a Pythagorean triangle of decision choices. On one side we rely upon our personal training and individual experiences. Another side (with far fewer options) offers evidence-proven therapeutic choices. The third side entices us with cutting-edge innovations. In the fast action of clinical practice we will usually default to the hypotenuse of our training and experience. The reality of clinical practice today falls short of the math; that is present-day clinical evidence plus cutting edge innovative technology does not equate to individual training, experience, and reason. Yet while this larger side may be our first resort, we need to condition ourselves and our students to remain self-critical and vigilant for old faulty dogma and new ideas that are better.

220px-Pythagorean.svg

[a= cutting edge innovation, b= verifiable high level evidence, c= training & experience]

 

Seven.          Health care questions.

What are the big questions in health care? As health care in this country undergoes significant changes, dictated by a variety of forces, it may be useful for us to consider health care not in the context of metrics (e.g. RVUs, length of stay, and cost per case), but rather in terms of our basic expectations and values. If most citizens and practitioners can understand and agree upon the larger questions of health care, the answers and the structures to provide them may come to us more readily.

I don’t think it should be up to any one subset of “the experts” to tell us the questions, for after all, that’s a sort of Bellmanism. The key questions should be derived more broadly, they do not belong solely to universities, medical schools, or schools of public health. They do not belong to state or governmental legislative or regulatory agencies. They do not belong to the AMA, the ACS, the AUA. They belong to the public – to citizens, patients, health care providers. My first loyalty lies within the last broad categories as a citizen, patient, and physician – memberships that convey measures of authority in offering, just now, a set of basic questions for our collective consideration. Whether these are the right questions is a matter for you to consider. What among them is right, what is wrong, and what is missing?

  • What is health care?
  • How should it be provided?
  • How is it improved and how does innovation occur?
  • How is it taught?
  • How is it funded and how are escalating costs managed?

 

Eight.            Choices.

While there may be no simple solutions for these questions, and whereas the “devil is in the details” clarity can be found in their deliberate articulation and informed public discussion. The first question is deceptively simple, but what of “health care” is a public good and in the public interest? Certainly vaccination for dangerous diseases, TB surveillance and therapy, mosquito control, and Ebola management should be public goods. When is health care screening – screening for TB, hypertension, or malignancies (which malignancies) – in the public interest? What basic commodities of health care must be assured to the public (to assure the public health) and what are the discretionary choices that should be paid for by the responsible recipients of those services? And what about recipients who are incapable of such responsibility? Is not antenatal, obstetric, and well-child care in the public interest? Who should make these decisions?

The time-worn bogeyman of “socialized medicine” has seen its day; socialized medical care has a heavy footprint in today’s USA and its called Medicare, Medicaid, Tricare, and the Veterans Administration. Pressing questions are related to funding, equity, and scope of each of these systems. The present binary argument between a single payer system or an insurance-based model, in my opinion, is wrong.

A single payer system, while convenient from the point of funding and health policy, is fraught with many problems, among them being loss of personal choice, dependence on politically-set budgets, restriction of innovation, and lack of competition. On the other hand, the idea of building an entire national health-care system on an insurance-based paradigm is faulty since basic health care (this first question, after all) is a complex life-long responsibility extending from antenatal months to the last days of life. Insurance for rare and unexpected catastrophes like liver transplantation, motor vehicle accidents, ALS, renal failure, and serious malignancy makes sense, but not “insurance” for expected life events such as childbirth, vaccinations, dental care, routine checkups, and screening for certain diseases. The bipolar choice could be compared to asking us to choose between the Post Office or Federal Express as the single national mail delivery service. Neither one alone would be a good provider. The competition between them and other delivery services makes each one leaner, more innovative, and more customer-centric. Health care of our population needs many avenues to be universal, fair, excellent, efficient, and innovative.

 

Nine.            An epilogue.

The epilogue to Kalanithi’s book, written by his wife Lucy, included one phrase that struck me: “Although Paul accepted his limited life expectancy, neurologic decline was a new devastation, the prospect of losing meaning and agency devastating.” [p.203] Ultimately, for most of us, those two things are what life boils down to – the meaning we find in life and our agency to do things that are meaningful to us and to others. Meaning is our ability to make sense of things. Sense-making may be a matter of simple practicality, knowing for example that 1+1=2, or it may be the more existential making-sense of our lives. Kalanithi made fine sense of his shortened existence. Lucy Kalanithi ends her epilogue in the book powerfully enough to make your eyes well up: “Paul’s decision to look death in the eye was a testament not just to who he was but who he had always been. For much of his life, Paul wondered about death – and whether he could face it with integrity. In the end, the answer was yes. I was his wife and a witness.” [p.225]

The content, style, and literacy of Kalanithi’s book makes it compelling and readable. Coincidentally, the book is visually accessible because of its typeface, which is called Bell, after John Bell (1745-1831) who produced the original design, described as: “a delicate and refined rendering of Scotch Roman” at the book’s conclusion (above quotation is bold Bell MT font on my computer, although via email or the WordPress blog site, deformation is expected).

 

Ten.              Tolling bells.

Cancer, sectarian violence, motor vehicle trauma, and heart disease remain high on the list of the Grim Reaper’s tools. Nearly 400 years ago last month (March 31, 1631) the cleric and poet John Donne died, from stomach cancer it is believed. Born in 1572, 6 years before Harvey, Donne grew up and lived his 59 years through difficult times amidst terrible sectarian conflict that makes our recent western paradigm of separation of church and state so praiseworthy. During the reign of Elizabeth I (1558 -1603) the Recusancy Acts, beginning in 1593, imposed punishment on those who didn’t participate in Anglican religious activity, extending to imprisonment and capital punishment. (These laws were ultimately repealed in 1650, although restrictions against Roman Catholics lasted in England and Wales until full Catholic Emancipation in 1829.) Donne’s parents were Roman Catholics, but the father died when he was four and John’s mother married a wealthy widower, Dr. John Syminges. Donne studied in Oxford and Cambridge but never graduated with a degree as he was unwilling to take the Anglican Oath of Supremacy. He then studied law in London. Donne’s brother Henry, a university student, was arrested in 1593 for harboring Catholic priest William Harrington. Under torture Henry betrayed Harrington who was tortured, hanged, and disemboweled in 1594. Henry Donne died in Newgate Prison of bubonic plague.

John_Donne_BBC_News

[Lots on his mind. John Donne c. 1595. National Portrait Gallery, London]

John Donne became an Anglican minister, Dean of St. Paul’s, and a poet. (His interesting later years were chronicled by Izaak Walton, author of the first book on fly fishing.) What’s relevant from Donne is Meditation XVII in Devotions upon Emergent Occasions that included this familiar phrase that is linked to Kalanithi’s idea of human relationality: No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend’s or of thine own were: any man’s death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.”

 

Thank you for reading What’s New and Matula Thoughts for this April 1, 2016

 

Matula Thoughts February 5, 2016

DAB What’s New February 5, 2016

 

Legendary Jedi Masters, teams,  & other considerations

3779 words

UM Hospital Postcard2

One.               Ninety years ago a massive hospital opened for business here in Ann Arbor, although its intent at that moment was not just ordinary hospital business. The intention was advanced clinical care, medical education, and research. These activities on that hill, comprising the three-fold mission of our medical school, would have substantial impact throughout the world of health care. Health care was evolving from the work of solo practitioners armed with their hands and a few tools to specialty based teams armed with deep knowledge of their fields and incredible technologies. Michigan’s first 2 urology trainees began their residency training that same year.

The advanced clinical care, medical education, and research offered at Michigan were at the cutting edges of possibility in 1926 and changed medical practice, pedagogy, and discovery over the next century. Hugh Cabot, chair of the surgery department and dean at the time, was the force behind the building (shown above in an antique post card) dominating this small university town. In addition to building the hospital, Cabot put together the University’s first coherent multispecialty group practice.  He also was Michigan’s first academic urologist with a strong record of clinical innovation, scholarly achievement and, beginning that year in 1926, urologic education. His first two trainees in Ann Arbor would come to fame well beyond this town and their field of urology, having gotten their start standing on Cabot’s shoulders, as it might be said. Reed Nesbit came from California, remaining at the University of Michigan for an extraordinary period of clinical innovation, education, and leadership in American medicine lasting more than 40 years. Charles Huggins came from Boston and would go on to win the Nobel Prize for demonstrating the hormonal dependency of prostate cancer. We’ve not quite matched that first cohort of residency training, although we have trained many superb urologists in the intervening 90 years.

The world of specialty training has changed much since those autocratic days of graduate medical education when It was considered somewhat of a gift for the few experts like Cabot to allow younger doctors such as Huggins and Nesbit to assist them clinically as, in exchange, they mentored and educated those trainees. Cabot realized that while educating the next generation was part of his duty it distracted him from his other obligations as well as costing time and money, yet somehow he decided to select those two young men to come work with him in Ann Arbor in 1926. This duty has gotten more expensive and distracting with onerous regulation and recognition that trainees are also “customers” in today’s world. As customers – along with patients, referring docs, our employees, and the public in general – their opinions and “satisfaction” concerning our efforts matters. We now measure satisfaction with tools such as the Likert Scale, although as we train the next generation of health care professionals their immediate satisfaction and pleasure are not our only responsibility to them and society.

 

 

 

Two.              The University of Michigan was the first university to own and operate a hospital, going back to 1869 when a faculty building was converted into a dormitory for patients undergoing surgery in the Medical School building. Nearly 60 years later the building, shown above in 1926, was the hospital’s fourth iteration. Built on the side of a hill, the front entrance was actually on the 5th floor of the structure. The admixture of a university and a hospital makes excellent sense in terms of the missions of education, research, and clinical care, although the operational implementation has been challenging. Complicating the challenge is the growing complexity of universities, the increasing specialization of modern health care, new and expensive technology, the economic/regulatory environment, aging populations, expanding comorbidities, international instability, and climate change. Yet for all these reasons, the role of the academic health center in large and strong universities makes more sense than ever. The basic unit of a university is its academic department while the basic unit of a health care center is the so-called service line, the smallest team unit that delivers a specific clinical service. Yet like any biological cells, these basic units are co-dependent. Our challenge is joining them together to create excellent clinical care, education, and research.

 

 

 

Three.           A primary necessity in academic medicine is its regeneration through the selection and education of its successors. This annual ritual brings new cohorts of medical students into residency programs, and four interns (PGY1s) will comprise Michigan’s class of 2022. This is twice Cabot’s inaugural class and seems about right for us now. Clinical practice has become far more complex since the days of Cabot and Nesbit, so residency training accordingly encompasses a greater range of knowledge and skills. The actual number of trainees is based upon clinical volume, institutional factors, and faculty talent. Whether four will be the right number in the future will be a topic of faculty conversation as we continue to match manpower to mission.

Faculty serve not just as clinician-teachers, but also as coaches and mentors, and after accounting for all residents and fellows our faculty to trainee ratio is 1:1. Although the public and much of the rest of academia view medical educators as people standing in front of students in classrooms, that is actually a rare circumstance. Our classrooms are operating rooms, patient bedsides, clinics, laboratories, offices, coffee shops, and cafeterias. These places comprise the gemba of medical education (the Japanese term gemba refers to the place where the work is done and is part of lean process terminology). The subjects include basic sciences, clinical sciences, surgical techniques, professionalism, E & M coding, research techniques, health care delivery, population management, team work, leadership, and teaching itself (pedagogy).

Residency training is the career-defining stage of medical education and one could claim it is the signature product of an academic health center, usually exceeding (sometimes more than twice) the time spent in medical school. Furthermore the numbers of our residency trainees here in Ann Arbor are roughly double those of medical students at any moment. In addition to the subjects mentioned above residents are coached to develop the habits of lifelong learning and teaching. Confounding these goals are regulatory pressures including the duty hour restrictions.

Five Michigan students wanted to go into urology this year and they all did extraordinarily well. Entering our program this summer will be Adam Cole (UM), Lauren Corona from Wayne State, Scott Hawken (UM), and Udit Singhal from Wright State. If our program allowed 8 residents per year we would have also kept our other 3 Michigan students, for I believe all 8 will add to urology and society very positively. And of course, they will be Nesbit Society members someday soon. David Kozminski will be going to the excellent Albany program to train with Nesbit alumnus Barry Kogan. Naveen Krishnan will be at Indiana (our sister Big 10 residency where Mike Koch is chair) and Heiko Yang will train at the University of California in San Francisco with Peter Carroll. I’m jealous of Barry, Mike, and Peter for getting these three superb students.

 

 

 

Four.              The Likert psychometric scale is commonly used in questionnaires that are becoming a large piece in the value equation of health care. Rensis Likert, the originator of the idea, grew up in Cheyenne, Wyoming. His father was an engineer for the Union Pacific Railroad and Rensis followed his dad working for the railroad during its 1922 strike. That experience in workplace conflict led to a lifetime interest in organizational behavior and communication failure. Likert then travelled east to the University of Michigan, obtaining a B.A. in economics and psychology in 1926. He continued east to Columbia University for a Ph.D. in psychology in 1932, where his thesis developed the idea of a system for measuring attitudes based on a 5-point scale ranging from “strongly agree” to “strongly disagree.” It was hardly a novel idea for students to rate their teachers, although evaluation was usually behind the teacher’s back, on occasions resulting in voting with one’s feet to find another teacher or mentor. The Likert Survey Scale, however, was the first validated psychometric evaluation system and it found broad use across many fields. In educational arenas it would give students a voice in their instruction and also provided the teacher a sense of the satisfaction of their audience.

Teachers, however, can become enslaved to evaluations and accordingly pander to their subjects, an outcome that does not result in effective teaching or mentoring. Effective teachers and coaches may need to push team members beyond levels of comfort. Popular culture makes this point nicely in the story of Star Wars, for who can forget Yoda pushing Luke Skywalker beyond his tolerance until the youngster bowed to his internal Likert rating of “strongly disagreeable” and walked away from his training prematurely, to the advantage of the dark force.

Yoda

[The legendary Jedi Master]

Sometimes we need to hear “disagreeable things” and to feel uncomfortable. The business author Jim Collins talks about the need for leaders to confront “the brutal reality” of situations. Health care no less than the business world has its share of brutal realities. We fail to train medicine’s future Jedi knights effectively if we protect them excessively from over-work or take pains to wrap criticism in flowery packaging. There were times during my residencies that I worked more than 80 hours a week, by choice or by necessity. Yet probably just as often my weekly work hours amounted to less. It is often claimed in the educational world that expertise in topics such as chess, piloting, or golf takes 10,000 hours of practice or experience. Perhaps urological skill takes more, a number that empirically looks like 20,000. Considering the rapidly changing basis of technology and science, as well as the modeling of professionalism and the need for vacations and some down time, five to six years at 80 hours a week goes by quickly.

Patient care, particularly in the surgical world, is not perfectly predictable and workplace service line demands and workforce culture should set the pace. If reasonable limits are consistently exceeded for no good clinical or educational limits, institutional leadership (program directors, chairs, or deans) must recognize and address the matter, or alternatively residents should air their grievances or vote with their feet. It is unfortunate that a few historic bad apples in the world of graduate medical education (e.g. the Libby Zion case) precipitated the present obsessive national regulation of resident work days.

 

 

 

Five.               Likert’s career. After graduate school Likert found a job with the Department of Agriculture and during WWII became Director of Program Surveys for the USDA and as the war progressed he also helped the Office of War Information, the Department of Treasury, the Federal Reserve Board, and the US Strategic Bombing Survey.

Likert, Rensis

At the war’s end political forces in Congress forced the Department of Agriculture to stop its social survey work. Likert’s team accepted an offer from the University of Michigan in 1946 to form the Social Research Center, that in turn became the Institute for Social Research (ISR) in 1949 when Dorwin Cartwright moved his Center for Group Dynamics from MIT to Ann Arbor. Michigan’s ISR fielded the 1954 double blind trials for the Salk polio vaccine. Likert remained director of ISR until his retirement in 1970. While his work centered around the attitudes of individuals he  also studied the function of teams in terms of management styles in the business world. He and his wife Jane applied their findings to educational settings, recognizing 4 basic styles: a.) exploitive authoritative, b.) benevolent authoritative, c.) consultative systems, and d.) participative systems. His elaboration of the linking-pin model is relevant in complex organizations today. Likert died in 1981 and is buried in Ann Arbor’s Forest Hill Cemetery.

 

 

 

Six.                 Pendulums swing in organizational systems, as is their nature. In previous iterations of health care education, just as in previous generations of athletic coaching, many learners suffered more than was necessary to achieve mastery of their games. In response, peer organizations such as Residency Review Committees, ACGME, NCAA, and even the United States Government assumed roles overseeing the respective training grounds. Oversight organizations, however, tend to become self righteous and in the pursuit of added value create regulatory over-reach evident now in the constraints of duty hour regulations and the mandated EHR.

While few can deny that a national standard for electronic health records is necessary, the EHR law went way beyond creating a standard to imposing cumbersome systems that traded away personalized health care and physician efficiency for billing efficiency and corporate enrichment. “Meaningful use constraints,” checklist orientation, and workflow standardization have altered the relationships between patients and providers to the satisfaction of neither.

People come to health care providers to solve problems, but problems are bound up in stories. Rarely is a patient’s story simple enough to be reduced to an ICD-10 code that may be addressed by a therapy expressed in a CPT code. This is not the personalized medicine that people desire. Let’s say that you have a large painful ureteral stone (ICD-10 N20.1) that might be solved by expulsive therapy, ESWL (CPT 50590), or ureteroscopy (CPT 52356). The choice takes a discussion that must account for many personal needs wrapped up in the patient’s story, a story that doesn’t easily fit the EHR checklist. The patient’s narrative is likely to involve significant comorbidities (as discussed here a few months ago ….) that may be physical, mental, or social. Furthermore, not all diagnoses, therapies, or co-morbidities actually have codes. For all the 150,000 ICD-10 codes and additional thousands of CPT codes in the books I often find myself at the computer during clinic struggling to find  a code that fits the problem I think I have discovered in a patient or the code for the solution I have in mind.

The failure of our massively expensive EHRs and health care organizations to respect the role and power of narrative in the essential transactions of kind and excellent patient care is gnawing at the heart of health care. While the exploitive-authoritative model Likert experienced at the Union Pacific Railroad is dissolving in most forward-thinking businesses it is establishing itself in healthcare. For this reason we can expect growing physician dissatisfaction to express itself in such things as unions and other forms of protest.

 

 

 

Seven.   

Coaches

[Three contemporary Jedi Masters of coaching and team-building – Chalmers “Bump” Elliott in center, Bruce Elliott and Fritz Seyferth on left and right]

Discussions of coaching and mentoring often default to the world of sports. This is no surprise since athletics have been a universal cultural experience throughout human history and remain even more so today from preschool to the Superbowl and from refugee camps to elite universities. The idea of coaching has crept from the athletic world into business organizations and professional work. We know today, through the examples of the sports world and the ideas of lean engineering that the best coaching is done at the gemba, or at least with the gemba close in sight or in mind.  Most great coaches will tell you that they are only standing on the shoulders of those who coached them or inspired them as coaches, and the individuals above would offer names such as Fritz Crisler, Pete Elliott, Jim Young, Bo Schembechler, and others including their high school coaches or examples from other sports.

All coaches share some similarities, although even within the athletic world coaching styles differ according to the nature of the sport or the culture of an institution as well as the personality of the coach and the needs of a particular team. Certain coaches are more exploitive authoritative than benevolent authoritative, according to Likert’s model, but most successful ones will have some consultative and participative elements even if not overtly visible. In fact all good coaches learn from each others’ plays and styles, in addition to learning from those they coach – for after all, the coach is a part of the team.

Not so long ago, in the days of Hugh Cabot and Henry Ford for example, leaders presumed they “knew it all” and that their decisions were final and best. The idea of the “wisdom of crowds,” as James Surowiecki and Scott Page explained in their books, was not a common belief.

 

 

 

Eight.             Coach Harbaugh got his team off to a good start last month at the Citrus Bowl, a stadium that we learned resulted from one of FDR’s WPA projects. Team size in American football today consists of 11 players in play per side, although when the first American football game was played on November 6, 1869 each team had 25 players. It was Rutgers vs. Princeton and who would have guessed that one of them would join the Big Ten nearly 150 years later? Rules then were set by the host school. In 1873 Yale, Rutgers, and Princeton agreed on some standard rules and set the teams at 20 players per side. Walter Camp of Yale in 1880 led rule changes that set the size at 11 players and introduced the snap to replace the scrum (scrummage), a method of restarting a play, taken from rugby.

Citrus Bowl

Team size was an issue for the Supreme Court, on this particular day coincidentally in 1937, when FDR attempted an historic over-reach. Article II of U.S. Constitution leaves it to Congress to determine the number of Supreme Court justices. The Judiciary Act of 1789 started our nation off with 6 justices. With growth of the nation Congress increased the number to correspond with the number of judicial circuits: 7 in 1807, 9 in 1837, and 10 in 1863. In 1866 Congress passed an act that the next 3 justices to retire would not be replaced, thus attempting to scale back the court, however in 1869 the Circuit Judges Act returned the number to 9.

President Franklin Roosevelt in 1937 on this day proposed a plan to enlarge the court by adding an additional justice for each who reached the age of 70 years 6 months, but refused to retire – up to a maximum of 15 justices. The motivation was more political than an attempt to match manpower to mission. The court-packing plan failed to muster enough support in Congress, although the president was still able to pack the court ultimately appointing a total of seven justices and elevating Harlan Fiske Stone to Chief Justice. A good coach might have cautioned FDR against interfering with the authority and structure of another branch (the judicial) of government, but presidents and other CEOs have a poor record of coachability. Clearly Roosevelt’s proposal was a moment of executive over-reach, but in his defense all branches of government, all agencies, and most organizations of any sort are self-programmed to over-reach. That is the Darwinian nature of things. Not just our presidents and leaders, but each of us needs some sort of coaching to keep our values, our missions, and our daily work in balance. I’ve found this very important in my time as chair, with the coaching of David Bachrach, a former administrator here at UM and later at MD Anderson.

Bachrachs

After a short time in any leadership position, surrounded inevitably with its own “zones of yes,” most of us start to yield to the dark side of the force in figuring that we have all the answers. A wise coach who has played in the game extensively, can find clarity, and doesn’t mind telling you unpleasant things you need to hear, is essential for success of the organization – and that success is ultimately the success that counts.

 

 

 

Nine.              Cells and organizations. Last month we also mentioned that the first use of the term cell, as a basic unit of life, appeared in Robert Hooke’s book Micrographia in 1665. The changes between Micrographia and today have been incredible and even a great mind like Hooke’s couldn’t have predicted today’s world of science and health care.

Micrographia

When Cabot, however, opened Michigan’s University Hospital 90 years ago he likely could have predicted most of today’s big issues in health care. These include specialization, new discovery, expensive technology, regulation from numerous quarters, third party payment systems, demographic changes, and increasing dependency on regional and national economies. The changes are coming at rapid fire and no single health care system is prepared to manage them. The changes impact the nature and financing of health care and all aspects of its educational and research components. Nevertheless, the basic dynamic of the doctor-patient relationship (in our Department of Urology we call this the essential deliverable of kind and excellent patient-centered care) and the basic dynamic of the teacher-student (or faculty-resident, coach-learner, mentor-mentee) are unlikely to change. This scenario predates the days of recorded history and is echoed in most human endeavors throughout classrooms, athletic fields, and in gembas everywhere.

 

 

 

Ten.

Chrtres cathedral

If someday your travels take you to the Loire Valley and town of Chartres in France you will notice a large and impressive cathedral that dominates the town, much as our hospital did here in Ann Arbor 7 centuries later. The church is one of 1031 World Heritage Sites, although to the discredit of our species ISIS is assiduously working to reduce that number. The south rose window at Chartres dates from 1221-1230 and beneath the spectacular dominating rose window sit 5 lancet windows, the central one featuring Mary carrying Christ. The lateral lancet windows illustrate New Testament evangelists on the shoulders of Old Testament prophets looking up at the Messiah.

Shoulders

(Left to right: Jeremiah carrying Luke (shown below in detail), Isaiah carrying Matthew, Ezekiel carrying John, Daniel carrying Mark.)

The metaphor of finding new perspective from the shoulders of giants long precedes this image and has been employed many times subsequently, most notably in Isaac Newton’s letter of 1676 to his intellectual rival Robert Hooke: “What Des-Cartes did was a good step. You have added much several ways & especially in taking the colours of thin plates into philosophical consideration. If I have seen further it is by standing on the sholders of Giants.” Coleridge said it again in 1828: “The dwarf sees further than the giant, when he has the giant’s shoulders to mount on.” Our teachers, mentors, and coaches become giants for us when we catch a glimmer of their perspectives, insights, and art. In their minds they may not at all consider themselves “giants” and nor do we even though our students, residents, and colleagues use our shoulders for a little start to their careers. All of us teachers and mentors of one sort or another in our lives, that’s how civilization works. Hippocrates, Osler, Cabot, Nesbit, Lapides, Schembechler, and Elliott achieved great distinction as giants in their times and fields, exemplifying the path for the rest of us.

 

We will get an extra day at the end of this month and it will be a Monday. Think of it as a glitch in The Matrix.

Best wishes and thanks for reading What’s New and Matula Thoughts this month.

 

David A. Bloom

Department of Urology, Ann Arbor

 

 

Matula Thoughts October 2, 2015

DAB What’s New October 2, 2015

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Change, colors, chloroplasts, mitochondria, & detachment

3048 words

 

Mich green

1. Michigan’s green landscape is changing now that October is here with the deciduous ritual of autumn colors creeping south at the rate of about 200 miles per week. Autumn colors in Ann Arbor, however, are not just botanic. October brings us deep into the heart of football season when maize and blue attract intense scrutiny. Legend has it that a group of Michigan students decided that the school colors should be azure blue and maize, but school officials didn’t make it official until 1912. Curiously the actual shades of maize and blue differ between the University at large and the Athletic Department.

Sincock Seats

[Above: Fall colors in Ann Arbor. Big House night game from Craig & Sue Sincock’s box. October 11, 2014.  Below: UM seal with distinctive azure blue, courtesy Brad Densen]

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2. Physicians once paid great attention to the green world, as plants were a prime source of medicines. This changed in the later 19th century, when modern medicine evolved with its verifiable conceptual basis of biochemistry, pathology, physiology, microbiology, pharmacology, etc. Before then medications fell into the area of study known as materia medica and botanic knowledge was a necessity for doctors. Leaves are green, by the way, because the dominance of chlorophyll masks out other pigments. As leaves age, green chlorophyll degrades into colorless tetrapyrroles, so that yellow xanthophyll and orange beta-carotene pigments take over visually, although they had been present throughout the leaf life cycle. Red pigments, the anthocyanins, are synthesized de novo as chlorophyll becomes degraded. After the non-green colors show up detachment and recycling of this year’s leaves soon follows.

442px-Pyrrole_structure

[Biochemistry refresher: Pyrrole, the five-membered ring shown above (C4H4NH), a colorless volatile liquid, was first detected by F.F. Runge in 1834 as a coal tar derivative. Pyrrole is a component of chlorophyll, other botanic pigments, as well as the red cell porpyrin heme, a co-factor of haemoglobin. Four pyrroles assemble to make up a porphyrin, and these molecules allow  numerous color options.]

I happened to see my first leaves of the season fall in early September when I was in Nijmegen, Netherlands at the semi-centennial celebration of the splendid urology unit of Radboud University.

Leaves

[Above: detachment in Nijmegen 2 weeks ago.

Below: What we look forward to this month: Ann Arbor foliage October 2014.]

Barton tree

 

3.  Change is an apt theme right now as it surely is in the air for health care. Coalescing organizations, new regulations, untried payment systems, intensifying competition, narrow networks, tiered access, new technologies, fantastic and fantastically expensive new drugs, are among the factors behind the unprecedented change. These changes are more than seasonal or market changes and they are putting things that we cherish at risk, namely the three dimensions of academic health care – education, research, and quality clinical care. Clinical care is the primary resource engine for academic health care centers (AMCs). This aspect of our mission is the mitochondria of AMCs, providing not just the context for education and research, but also the bulk of its sustaining funding. Furthermore, clinical care is the moral epi-center and the essential deliverable of AMCs.  While American health care is not perfect, it isn’t better in most other places on the globe. Consider the options – in a perfect world how would you manage and fund a piece of society and the economy as necessary, complex, and large as health care? A purely market driven system would leave out a huge chunk of the populace and would not service the interests of the public health at large. Purely governmental systems are perpetually under-resourced, funded at the whim of rotating politicians, bureaucrats, and accountants. Canada, at this moment in time, seems to be the remarkable sole exception to this seemingly natural law. I’ve worked in England’s National Health System (NHS) twice in my life, and am somewhat familiar with its ups and downs, but that natural tendency of impoverished dependence on central governmental funding and accountancy management is inescapable. The NHS was intended to be the exclusive source of health care for the British public, but a growing private sector of health care in the U.K. provides some balance and competition.

 

4.   My friend Karin Muraszko, chair of our Neurosurgery Department, recently gave me a book called Do No Harm by Henry Marsh, a neurosurgeon in London. I read it cover-to-cover and thought it remarkable. The value of appropriate and necessary detachment for a surgeon is one of three things that jumped out at me from the book. The second is that natural law I mentioned whereby a national health system budgeted by politicians and managed by accountants does not serve patients, families, health care workers, or other essential stakeholders well, or kindly. The third point is that duty hour restrictions enforced by national agencies (governments, regulatory organizations, professional groups, or payers) are not conducive to professional education, competence, or expertise, much less excellence. The 48-hour work-week for neurosurgical trainees in Europe might be compatible only with a 15-20 year period of training, but not much less. While a few older surgeons like Henry Marsh are still around, and perhaps an occasional excellent new neurosurgeon might emerge miraculously from the sad current European training paradigm, I fear for the next generation of patients with neurosurgical problems on the other side of the Atlantic. Even more frightening is the thought of the subsequent generations of neurosurgeon-educators that will emerge. For them duty hours, accountancy management, and patient “hand-offs” may trump the sense of professionalism and duty they might vaguely recall having seen in the vanishing breed of Henry Marsh.

 

5.   One of the most important rituals of academic medicine is the selection and education of our successors and just now we are in the midst of this with a new cycle of applicant interviews for our residency. Residency training is the career-defining stage of medical education and one could claim it is the signature educational product of an academic health center, usually exceeding (sometimes by more than twice) the time spent in medical school. I don’t think laymen or our central campus friends fully understand this reality.  During our residency training at Michigan young physicians learn the state-of the-art clinical skills of urology, its conceptual basis, professionalism, teamwork, and leadership. They develop the habits of lifelong learning and teaching. When I finished training in general surgery at UCLA, I became a member of the Longmire Society, just as our residents in urology at Michigan become members of the Nesbit Society. The Longmire Society certificate includes a motto that features the words: detachment, method, thoroughness, and humility.

Longmire

These were presumably the ideal characteristics of a Longmire-type surgeon, and indeed suited “the boss” well. Yet the inclusion of detachment as an ideal characteristic puzzled me at first and didn’t seem quite right as it seemed to imply a lack of compassion and empathy, although I’ve since come to understand the importance of detachment with more subtlety. As I write these thoughts the irony of the term “duty hours” strikes me: duty vs. duty hours. Of course, no one can be “on duty” all the time, but people like Henry Marsh, in addition to their sense of necessary detachment, carry their professional duty with them as best they can throughout their careers day-by-day and night-by-night. The on-and-off duty switch is not flicked frequently. Professionalism, nevertheless, carries with it some danger: we become self-righteous in our jobs and professions. We tend to define the limits of our duty more according to the convenience of our job descriptions than by the needs of the public. This does allow us some detachment, but sometimes more for our own sakes than the sake of those among the public who might want our help or kindness.

 

6.   Change is in the air locally at our own academic health care center in Ann Arbor. We are modestly reorganizing our structure and governance, and a new strategic planning process is in play. As Dwight Eisenhower said: “… plans are worthless, but planning is everything.” (Remarks at the National Defense Executive Reserve Conference. 11/14/1957) We urgently need to figure out how to balance our growing patient population with our mission, with our facilities, and with the changing landscape of health care. At the September 17 Regents Meeting changes were made to our organizational structure that should help us build and execute a strategy that fits us well and secures our success in the brave new world of academic health care. Effective January 1, 2016 Marschall Runge, will add the role of medical dean to his position as Executive Vice President of Medical Affairs. David Spahlinger will become president of the clinical enterprise (a new name for this entity is pending; we have been using the term UM Health System) and Executive Vice Dean of the UMMS for Clinical Affairs. New positions will be recruited for a chief academic officer, a chief scientific officer, and a chief information officer for the academic medical center. A chief value improvement officer has been hired by Dr. Runge. Tony Denton will be the Senior Vice President and COO of the clinical enterprise. [Below: Tony & Marschall] Doug Strong, our former CEO of the hospital and most recently VP for Finance & Business of the University will be retiring after a long run of distinguished service.

Marschall & Tony

 

7.   300px-Julius_Sachs  Born on this day in 1832 was Julius von Sachs, in Breslau, Kingdom of Prussia. We might not be inclined to celebrate his name now 183 years later, but we really should. A curious youngster, probably just like you once were, he had an early interest in natural history, which in 19th century Europe and North America was the term used for what today we call science. With a Ph.D. from Charles University in Prague in 1856 he embarked on a career in botany. His academic career took him from Dresden to Bonn to Freiburg and then to the University of Würzburg as chair of botany in 1868 where he spent the rest of his career, contributing greatly to the study of plant physiology. He is credited with the discovery of the chloroplast, a subcellular unit in which the chlorophyll pigment packs energy from sunlight into molecules ATP and NADPH while freeing oxygen and producing carbon dioxide. Like mitochondria, chloroplasts have their own DNA and are believed to have been inherited from an ancient ancestor, a photosynthetic cyanobacterium eaten up by ancient eukaryotic cell that happened to be hungry at a certain lucky moment far back in time. A similar moment of ingestion happened somewhere around then when another hungry cell devoured an organism that turned out to be the ancestor of mitochondria, the internal engine for animal cells. Chloroplasts and mitochondria are the resource engines for all life forms beyond the most primitive ones.

 

8.   I have a friend who sometimes says: “Change is inevitable, but progress is optional.” [On Wikipedia the quote is attributed to Tony Robbins, motivational speaker.] Health systems nationally as well as here locally in Michigan are in the midst of change, but we are hopeful that our local changes, here at least, represent progress. The demand for our clinical services in Ann Arbor is growing. I remember not many years ago our health system clinic visits were well under a million a year and we thought we were busy. Our most recent fiscal year (FY 15) produced 2,123,746 visits – representing a 6.1% increase just over the previous year, of which return visits constituted 4.7% and new patients were up 15.3%. The pressure on our exam rooms, faculty, staff, operating rooms, and hospital beds has been painful. We need to manage our health care enterprise better to fulfill the expectations of patients and our community, as well as to enhance our educational and research missions. This cannot be viewed from an accounting mentality as a zero sum game with one mission at the expense of another, but rather as a synergistic triad, with the clinical mission as the moral center, the context for education and research, as well as the prime economic engine.

 

9.   My first box of crayons when I was a toddler offered a half dozen colors and I didn’t notice or imagine at the time that many more colors could exist. If you glance quickly at a rainbow or the light from a prism that’s not such a naïve belief.

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[Reflection from a glass door on the floor of my in-law’s house in Waterloo, Iowa. Summer 2015]

However, over time in childhood my crayon boxes got larger with many more colors than I could have imagined. A 64 pack of crayons was astonishing discovery for me.

Standard_Crayon_Ad

220px-Crayola-64

Nowadays, kids on their iPads can sort through literally thousands of colors. This in turn should be no surprise because on inspection the spectrum of light is not an array of discrete quanta of color variations (at least, not that we know!) – it is in reality a spectrum. This increasing complexity derived from our attention is matched throughout the world today in the increasing number of cable TV channels, the proliferation of presidential candidates, the growing number of health care specialties and focused areas of medical practice, the 10-fold increase medical diagnostic codes effective this year (ICD-10), expanding sectarian conflicts, and gargantuan expansion of worldwide refugees.

 

10.   The 50th anniversary of Nijmegen Urology was a wonderful celebration they shared with international guests from Japan to Italy to Ann Arbor. It gave me some ideas about the upcoming anniversary of Michigan Academic Urology in 2019. My inclusion in Nijmegen was due to the luck of having Wouter Feitz, their chief pediatric urologist, spend three months with us in Ann Arbor many years ago. Nijmegen, the oldest city in the Netherlands, is situated on the nation’s eastern edge, next to the German border. Radboud Medical University contains a superb urologic unit that happens to be an epicenter of European Urology politically as well as geographically. There, under Frans Debruyne, the European Association of Urology got its start and now, headed by Peter Mulders, the urology unit continues to excel.

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[Past & present chairs of Nijmegen Urology. Above: Frans Debruyne. Below: Peter & Cindy Mulders]

Peter & Cindy Mulders

The innovative academic celebration was focused around specific patients in the various domains of urology and yet it explored the cutting edges of discovery and therapy. Our pediatric session featured the faculty at Radboud, Wouter Feitz, Barbara Kortmann,  Robert De Gier, and Ivo De Blaauw, with Raimund Stein of Mainz and Mannheim along with myself as guests.

Raimund, Maie-Jose, Wout

[Above: Raimund, Marie Jose & Wout Feitz. Below: Barbara & Robert]

Barbara & Robt

 

Since our session was on the opening day of the meeting, Wout and I skipped the second day to visit the Mauritius Museum in The Hague, on the western edge of the “Low Country.” The newly restored museum, a lovely historic house in the midst of the complex of government buildings known as the Binnenhof, houses Rembrandt’s great Anatomy Lesson of Nicholas Tulp [below], Vermeer’s Girl with Pearl Earring, and The Goldfinch by Fabritius. These great works and others compel thoughtful attention.

Tulp

Every year on the third Tuesday of September, which occurred the following week in the nearby Ridderzaal (Great Hall), the King delivers The Speech from the Throne. Wout and I happened to walk by after the room was set up for the event and on public display.

Ridderzaal

[Ridderzaal]

This Dutch tradition is mirrored in the State of the Union address in the United States, and in the annual State of the Medical School speech at our local level in Ann Arbor. Jim Woolliscroft (seen below), our medical school dean performed this task admirably for nearly a decade, just as Allen Lichter had done as our previous dean. Both were great leaders, colleagues, physicians, and educators. They have my greatest admiration for their work in guiding the UMMS through challenging times. Marschall Runge is amply up to the task for our next big steps as an academic health care enterprise in the new combined role.

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The trees in the Netherlands during my recent visit had just a few patches of autumn colors, although some leaves had already changed enough to detach and fall.

Hague tree

[Above: tree with patch of yellow. Below: early leaves on the ground near Binnenhof]

Hague leaves

From the air as I left the Netherlands the long-lasting and combined effects of those primeval cellular meals of chloroplasts and mitochondria were in full display on the ground below. The green landscape is an obvious credit to the chloroplasts, however the fact that a large percentage of the land, although actually below sea level, is now dry land must be attributed to mitochondrial life forms, especially ours. Thanks to human ingenuity and industry 17% of the Netherlands surface area has been reclaimed from the sea and only 50% of the country’s land is over a meter above sea level. Out of my view from the air and during my brief visit to Holland was the immediate staggering refugee crisis, in Europe below and the world at large. A recent JAMA viewpoint from the UN High Commissioner’s Office on the state of the world’s refugees is worth reading [Spiegel. JAMA 314:445] The UN Refugee Agency counts 60 million forcibly displaced people worldwide at this date and half of them are children. This situation must be charged to the mitochondrial side of the Earth’s ledger and those sorry stories of our failures as a species continue to reshape the planet.

Syrian toddler

[Syrian toddler – heartbreaking picture from last month’s news compelling our attention or detachment]

 

Postscript. It’s been a busy month academically and just last week I had the honor of being the Lloyd Visiting Professor in Portland, Oregon as a guest of Steve Skoog, John Barry, and Chris Amling. It is a great, storied department and excellent residents presented complex cases. I was mercifully given most of Friday morning off, allowing me to watch the televised visit of Pope Francis to the September 11 Memorial in NYC. The interfaith prayer service was remarkable with its rich array of colors and beliefs, connected by a shared overarching faith in mankind. The Pope’s presence and his comments offer inspiring counterbalance to the sobering image above and destruction memorialized at the Twin Towers sites. The multicultural colors assembled at that prayer service, symbolizing the rich potential of mitochondrial life and humankind, are the most impressive colors of this autumn.

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Thanks for reading What’s New, a posting from the University of Michigan Department of Urology, and Matula Thoughts, its blog version (matulathoughts.org). More on the department can also be found at: medicine.umich.edu/dept/urology.

David A. Bloom

Matula Thoughts September 4, 2015

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

 

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

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

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

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

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

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

 

3.    Sept Heures

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

 Feb 1848

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

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

Napoleon III

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

 

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

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

EMU AAUP

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

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

Sutton RI

[Sutton RI, The No Asshole Rule. 2007 ]

 

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

 

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

John Quincy Adams

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

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

 Deweytruman12

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

 

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

220px-Satisfaction-us

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

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

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

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

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

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

Retreat

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

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

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

 

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

 

9.    Shinola

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

 Rick

 

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

 Runge, Johnson

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

 

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

David A. Bloom

 

Matula Thoughts July 3, 2015

 

Matula Thoughts July 3, 2015

Independence, PGY1s, peonies, & art.

3673 words

 

©Photo. R.M.N. / R.-G. OjŽda

©Photo. R.M.N. / R.-G. OjŽda

Wash Monument

1.     It’s July and peasants farm and shear sheep outside the protective walls of a castle in the beautiful panel of the renowned 15th century illustrated manuscript, Très Riches Heures du Duc de Berry. Life was safer within the castle walls than outside them. The authority in charge of the castle and grounds was a nobleman governing locally on behalf of a distant ruler and the governance was absolute. Many Julys have come and gone since the Duke of Berry (600 Julys since 1415) and government has become more representative throughout much of today’s world for villagers, city folk, and the rest of us who perform the daily work of civilization. The relationship between the authority we call government and “the people” has evolved based on principles extending back to the Magna Carta 800 years ago (June 15, 1215) and even before.

Magna Carta

[Magna Carta Brit. Lib. 4000 or so words in Latin on sheepskin]

The principles of authority for the United States of America are seated in the Declaration of Independence, adopted by the Continental Congress on July 4, 1776. If you’ve not read the book published last year by Danielle Allen, Our Declaration, you should do so this summer. It is an amazing study and quite readable. As discussed previously on these pages of What’s New and Matula Thoughts, Our Declaration will give you, among many other things, a more sophisticated sense of the idea of equality than you likely now have.

declaration-of-independence

[1337 well-crafted words]

When the three Limbourg brothers of Nijmegen produced the “very richly decorated book of hours” for the Duke of Berry, the Duke probably felt little sense of equality with his workers. In some parts of today’s world things remain little different than in the days of the Très Riches Heures when dukes and kings had total unchecked authority over their subjects. Such nations are rarely successful in terms of aggregate innovation, intellectual contribution, education, environmental stewardship, industrial production, or social justice. Conversely, most modern nations today enjoy a shared belief that all people are equal before the law. In these places where the ideas of representative government, equality, personal liberty, and cosmopolitanism take hold, the potential of the human factor is unleashed and creativity emerges on a large scale. History shows that, when people have freedom to achieve their potentials, individual happiness and general human progress are served far better than when the state or crown decides what’s best for its people. Tomorrow we celebrate that particular success of government by the people, for the people, and of the people in our nation. Yet, these aspirational ideals remain under challenge not only by human imperfections in their implementation, but also by today’s iterations of tribalism, despotism, human subjugation, sectarianism, extremism, and war. The divergent symbolism of a castle and protective walls on one hand, and our iconic monument of an open society is striking.

 

2.     With July comes a new class of interns (PGY1s, residents) and fellows. I’ve enjoyed being a part of this cycle for many years. Our careers flip by in the blink of an eye and I myself was at that early stage of medical education not so long ago. Although relatively clueless back then, I had the ambition of becoming a credible children’s surgeon of one sort or another. With influences like Judah Folkman, Rick Fonkalsrud, Bill Longmire, Don Skinner, Will Goodwin, Joe Kaufman, and Rick Ehrlich, I was inspired to push ahead toward that ambition, but felt a long way from my goal and quite distant from a place in the “establishment” of pediatric surgery and urology. A year in London following the footsteps of David Innes Williams gained me a slight bit of early credibility in addition to lifelong friends in urology – Robert and Anita Morgan, John Fitzpatrick, and Christopher Woodhouse. A couple in the Royal Shakespeare Company, Mike Williams and his wife Judi, further broadened my perspective on the world, and I often think back to Mike’s description of their work as that of “travelling players.” This metaphor applies to us in academic medicine – we are travelling salesmen indeed, going here and there to sell our ideas, observations, clinical experiences, and research findings at national meetings and during visiting professorships. On my return from London I experienced an incomparable month with Hardy Hendren in Boston, filling a notebook equivalent to the size as that from 11 months in London. During that stay I further was schooled in gracious hospitality by Mike and Connie Mitchell and John and Fiona Heaney. Wonderful reminiscences and the start of deep friendships. Our residents and fellows are now assembling their own stories of educational experiences, no doubt as rich and meaningful to them.

 

3.     Most people at certain times of their lives entertain the nagging question of the meaning of life. The question comes up in good times or bad, in the midst of crises, or even randomly. It is too big a question to answer in a general sense and certainly beyond the reach of these small essays. Maybe it’s a silly question, a human conceit, for in the grand scheme of things it could be argued that the meaning of geology, for example, is of no less significance as a question. In the specific personal sense many people find life’s greatest meaning lies in the ways they individually make their lives useful to others. In this sense, then, the meaning of life is simply its public relevance. This might well be Darwin’s ultimate revelation: a life’s meaning is found in its specific relevance today and in its more general relevance to the tomorrow of future generations. The desire to do things for other people is deeply established in our genes and has been reinforced by millennia of human culture. Not only do we seek to have meaning individually to others and to our society, but we are compelled to construct a world where our generation’s children can create their own meaningful lives. It probably seemed easier for the kings, queens, and noblemen in the days of the Duke de Berry. They were born into a world where their meaning (in terms of the faulty surrogate of their self-importance) was pre-ordained, but that world didn’t offer much of a chance for anyone else, hardly a sustainable Darwinian scenario. Self-importance is a biologic necessity, but its socially-acceptable expressions occur across a spectrum with Mother Teresas on one end and Donald Trumps at the other.   Off that spectrum, deranged and delusional self-importance leads to shootings, bombings, and beheadings – public slaughterings designed to induce terror and 15 minutes of “fame” that in fact become horrendous perpetual shame for the perp. Random tragedy still stalks us and may never disappear, but our responses as a society are sometimes great and inspiring, as we witnessed in Charleston SC one week ago today.

AME Church

[Emanuel AME Church, Calhoun St. Charleston SC. June 30, 2015. DAB]

In spite of the personal good fortune of many of us today, our gift of freedom has not been making the world a better place uniformly. One bit of evidence that it’s not: the UN released figures last month showing that 60 million people, half of them children, are fleeing chaotic lands looking for safety, food, and asylum. This is a staggering and unprecedented number. It is mentally incomprehensible. Another bit of evidence: Pope Francis’s recent encyclical Laudato Si, warns that our failure of planetary stewardship has left even larger numbers of mankind living in piles of filth and at risk from effects of deleterious climate change. An article about this 192-page document said: “Pope Francis unmasks himself not only as a very green pontiff, but also as a total policy wonk.” [Faiola, Boorstein, Mooney. National Post (Toronto) June 19, 2015. A11]

 

4.     Last season’s interns are now seasoned house officers (PGY2s). They have performed admirably and are well on their way to becoming excellent urologists. Just as we will make them better, they will make us better. We look forward to their full-bore immersion in urology starting now.

PGY1s 2014 copy

[PGY2s:Ted Lee, Ella Doerge, Parth Shah, Zach Koloff]

Our new interns (PGY1s), mentioned here last month, have just come on board. When I started in that same position at UCLA on July 1, 1971, I stepped right into the game of hospital medicine, taking orders from the higher level residents, watching them and the attendings at work, and anxiously taking call, hopeful that a disaster wouldn’t blow up around me. The world has changed and now we give the new medical school graduates days of preparation for the complex systems of healthcare, the explicit and implicit expectations of their daily work, the hierarchy of graduate medical education, and the local idiosyncrasies of the University of Michigan (e.g. when we put on gowns and gloves in the OR the left hand is always gloved first). Only after a deliberate program of “in-boarding” do our new interns step into the real-time practice of clinical medicine. We hope the new members of our urology family will embrace our sense of mission and values. We hope they will pick up the professionalism of our faculty, staff, and their senior residents and fellows. We hope they will learn the histories of our department and institution and become inspired by those stories. We hope they will learn their craft and become superior in providing our essential deliverable: kind and excellent patient centered care, thoroughly integrated with innovation and education at all levels. The fact is, looking at our finishing chief residents and fellows this year, Michigan urology trainees are superior and we expect them to get even better throughout their careers.

 

5.     While governments, in many nations, have become more representative and recognize that they exist for the people they represent, one unintended, but inevitable consequence is that they become self-righteous. Authority corrupts itself. This happens today no less than it did for any of the Dukes of Berry and their counterparts over the past millennia. We should be wary that self-righteousness of large organizations is a feature of all self-organizing systems. This propensity is seen in the reordering of our haphazard health care system, for example in the ill-conceived HITECH Act that forced the jettisoning of perfectly good electronic medical record systems in favor of a few clunky propriety systems that satisfied arcane details of the law including the mandated “meaningful use.” We also see this in the overwrought “Time-Outs” in the operating rooms that default individual responsibility to a team check-list. (As a pilot in training, when I was a resident, the checklist was the responsibility of the pilot and co-pilot, not a formulaic team exercise of everyone on the airfield.) I thoroughly believe that health care, surgery most especially, is a team activity and that rigid hierarchy is not conducive to a highly performing team. However, rote adherence to a formulaic “Time-Out” for all operative procedures is equally counterproductive. We hope that the next generation of physicians, especially the urologists we educate, will not be taken in by regulatory self-righteousness of third party payers, national professional boards, state boards, and hospital systems so as to believe that the practice of medicine is a checklist, patients are clients, that a patient’s story is a dot phrase or series of templates, and that time-outs do not obviate Murphy’s rule. No check-list or algorithm can substitute for individual sensibility (and anxiety) of the operating surgeon. The formulaic and monitored checklist ritual, in fact, defuses the sensibility. Finally we pray that the ancient Hippocratic idea of listening to and looking at the patient (and the patient’s family) is where medical practice must begin and end – not with the computer and electronic health care record.

 

6.     Visiting professors challenge us with new ideas and perspectives. They offer our residents and fellows a more cosmopolitan view of the world of urology, and visitors take away strong impressions of the Michigan Urology Family. The same happens when we visit other institutions and see how their residents learn. I was recently at the University of Toronto as Bob Jeffs visiting professor at the time for their fellowship graduation and was duly inspired by the faculty, residents, fellows, nurses, and systems that Marty Koyle and his team have developed at Sick Kids’ Hospital. They have some great innovations that might fit us well. The children’s hospital is vibrant, welcoming, and user friendly.

Sick Kids fellows

[At Toronto Sick Kids: Kakan Odeh, Keith Lawson, Frank Penna, Paul Bowlin, DAB, Marty Koyle, Joanna Dos Santos]

Sick Kids

[Toronto Sick Kids Atrium & lobby from urology & surgery floor]

In Ann Arbor we recently hosted visiting professor Tim O’Brien from Guy’s Hospital in London and he gave a wonderful talk on his work ranging from bladder cancer to retroperitoneal fibrosis. He explained that he has given up doing clinical trials due to the overbearing regulatory paperwork and processes involved in setting them up and implementing them in Great Britain. Tim used a phrase that “the many were controlling the few” in the quagmire of clinical trial regulation. This is the opposite of the Duke de Berry’s situation where the few controlled the many and it begs the question: What is sovereign in a society and what is the source of its laws? It seems right that the people in a society should ultimately be sovereign and that the source of its laws should derive from cosmopolitan human reason and experience. Rules, however, should not be so oppressive as to impede the function and flourishing of the workers. A sheep cannot be sheared well and efficiently by a committee, nor can a bus be driven by a team representing all the diverse interests of the stakeholders of the passengers, neighborhoods of passage, and owners of the bus. Society has to trust its workers to a great extent, knowing that some mistakes will be made and accidents will happen, although minimized by means of education, training, sensible rules, and systems. It seems that clinical trials, and perhaps much of modern medicine driven by HITECH mandates, ICD-10, and other regulatory burdens is not flourishing. Anyway, Tim gave us a terrific visit and showed that we share many regulatory impediments with the U.K.

Tim O'Brien

[David Miller, Tim O’Brien, Kurshid Ghani at Grand Rounds in Sheldon Auditorium]

 

 

7.     Chiefs dinner Chief residents’ dinner. Our residents go from newly minted graduates of medical school to skilled genitourinary surgeons and excellent clinicians in a matter of 5 or so years. In that time we, as faculty, work with them initially as teachers, but increasingly as colleagues during the progression of their training. It is said that it takes around 10,000 hours of practice to become proficient at chess, golf, piloting, piano, or other specific tasks. The evolution of graduate medical education in urology to a 5-year program points to a gestational period of around 20,000 hours to achieve competency as a genitourinary surgeon. Our expectation at Michigan, however, goes beyond mere competency. We have a strong track record of producing not just urologists but the leaders and the best in urology, and this year I believe we did it again. Our yearly graduation dinner (pictured above) for the completing residents and fellows is a signature event in our calendar. We held it at the University of Michigan Art Museum for the first time this year. As intently as we work with our residents throughout the years of their training, the narratives of their lives, as told so excellently this year by their fourth year colleagues, Amy Li, Miriam Hadj-Moussa, and Rebekah Beach offered entirely new perspectives on our chiefs – Noah Canvasser, Casey Dauw, and Joanne Lundgren. We heard “the rest of the story” for these three who have come a long way from novice PGY1s. They have withstood the intense pressures of high-stakes clinical work in the ORs and at the bedsides. They have studied hard to compete in a rarified intellectual environment of high stakes exams. And they have solved problems for patients and eased their anxieties in the high stakes of urological disease and disability. Still, their learning and practice must continue, and the stakes only get greater as our graduates advance in their careers, but they have given us confidence that they will become the leaders and the best of urologists and physicians. Our graduating fellows, a notch higher on the learning ladder, have been equally superb and have now become truly independent: Lindsey Cox, Sara Lenherr, and Paul Womble.  The art gallery was an appropriate place to celebrate this milestone with them and their families. The Shirley Chang Gallery in the Art Museum is an especially lovely space to stroll and reflect.

 

8.     The four “Rs.” The world provides as many opportunities to stroll and reflect as individual imaginations allow. A few years ago our friend Bill and Kathleen Turner (Bill was chair at the Medical University of South Carolina as well as Secretary-Treasurer and then President of the American Urological Association) a few years back took us to Mepkin Abbey in South Carolina where a dozen or so Cistercian monks have developed a community with open gates for visitors to come stroll and reflect.

Mepkin

The unofficial motto of the abbey is: read, reflect, respond, and rest. Reading intends the sense of thoughtful examination of the world around us visually, literally, auditorily, and emotionally. You don’t have to go to exotic abbeys and other places to perform the four “Rs.” Here at home you can reflect in places like the Shirley Change Gallery and in May and June, you can wander in the University of Michigan Peony Gardens. These were designed and established in 1922 with many of the original plants donated by William Upjohn, an 1875 graduate of our medical school. The collection consists mainly of one species, Paeonia lactiflora, blooming in pinks, whites, and red. The peony is named after Paeon, a pupil of the Greek god of medicine Asclepius. When the teacher became dangerously jealous as his student began to outshine him, Zeus intervened to save Paeon by turning him into the flower. Thus you might argue that the peony symbolizes education’s ultimate aim – the success of producing students who outshine their teachers. The root of the peony is a common ingredient of traditional Chinese, Japanese, and Korean medicine. Indiana has made this its state flower.

Peonies Yun_Shouping Freer

[Peonies by Chinese artist Yun Shouping, 17th century. Freer Gallery]

Peony gardens

[UM Peony Garden, June 7, 2015]

 

9.     Hippocrates allegedly said: Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. According to the way I read this enduring aphorism and the way it is punctuated, the fleetingness of life and durability of art are linked as one thought. Life creates art, but art transcends life, and being passed across generations epigenetically, art changes life by enhancing it, inspiring it, or altering its perceptions. My late aunt Evelyn Brodzinski, a painter throughout her life and a student of visual arts, once said in reply to my question as to what, actually, constitutes art “Art is anything that is choice.” In the process of creation, selection, and omission of material and information people produce content that, presumably, had some meaning to the artist. Craving meaning in our lives, we find value in inspecting the visual, literary, or musical content that had meaning for their creators. When we started the Chang Lecture on Art & Medicine in 2007, in honor of the Chang family of artists & urologists, we hoped to offer a yearly lecture that would link the 2 essential human interests of art and medicine in some way. The choices thus made by our lecturers over the years have been amazing, and last year’s lecture by James Ravin, ophthalmologist and author of the book, The Artist’s Eye, was superb. I eagerly anticipate this year’s talk by Pierre Mouriquand who is both a pediatric urologist and an accomplished artist.

 

The Chang Lecture, targeted to a general audience, has attracted growing number of friends and members of our community. “Public goods” of our university such as the Chang Lecture and the Peony Gardens are part of the social compact between the University of Michigan and its community.

Chang 2013

 

Chang 2014

[Top: Chang Lecture 2013; bottom: Hamilton Chang, James Ravin, Dr. Cheng-Yang Chang]

 

Tom & Sharon 2013 copy

[Tom & Sharon Shumaker, loyal Chang Lecture attendees. Tom passed away in January this year.]

 

10.    Universities are the single institutions of civilization that exist for tomorrow. At the individual level they provide a framework for individuals to find their specific relevance as well as to understand the cosmopolitan nature of the world and their responsibility in it. In the larger perspective they create new knowledge through inquiry and research to provide the ideas and technology of the future. It is no accident that the largest piece of most great universities has become the health care enterprise. This is totally appropriate since health care is a dominant part of the GDP, it ultimately affects everyone, and economically it employs 1 in every 6 citizens. The bedrock of the best medical school departments consists of its faculty and the glue to secure the best of the best is the endowed professorship. Last month we held a lovely ceremony in which we turned over three existing endowed professorships to three faculty members who will carry the names of the professorships along with their titles: Khaled Hafez the George Valassis Professor, Ganesh Palapattu the George and Sandra Valassis Professor, and Julian Wan the Reed Nesbit Professor. They are superb surgeons, noteworthy thinkers, and astute clinicians. The endowed professorships allow them a little independence from the daily pressures of clinical effort and funded research.  These three are smart and kind people of the highest order and I’m lucky to call them colleagues and friends. They epitomize the cosmopolitan nature of our department, medical school, and university. Cosmopolitanism is a term I’ve come to appreciate through the work of Kwame Appiah (another author for your reading list!) and it consists of the belief that all of us human beings belong to a single global community with shared values and principles. Julian, Khaled, and Ganesh will be teaching our next generation of physicians and producing useful new knowledge in the milieu of our essential deliverable: kind and excellent clinical care. Someday, their successors – the future Valassis and Nesbit chairs – will be doing the same in the world of tomorrow that we may hardly be able to predict, but that we have thus prepared for amply.

Triple prof

[Julian Wan, Khaled Hafez, Ganesh Palapattu]

 

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

David A. Bloom

 

 

Matula Thoughts June 5, 2015

 Matula Thoughts June 5, 2015

(2686 words)

Summertime, wolverines, universities & other disparate thoughts from a clinical department of medicine at the University of Michigan

 

1.     Huron River  June at last. Even though clinical medicine is a 24/7 business, in contrast to the seasonality of the university calendar, we can’t help but notice that summer has arrived. Ann Arbor is a glorious place to be this time of year when you can walk along, fish, kayak, or canoe the Huron River (shown above with the Gandy Dancer in the distant background). Our applicants for residency training from the west coast or south see none of this lovely environment when we interview them in late November, a real recruiting disadvantage. Nevertheless, we have again recruited a superb resident and fellow cohort to start training with us next month. Spring and summer also bring the pleasure of seeing and hearing the birds in our neighborhoods. Surviving another rough winter and hatching their 2015 chicks, they bring to mind John James Audubon, who, born 230 years ago (April 26, 1785) in Haiti, documented and detailed all sorts of American wildlife, birds especially. His Birds of America is thought to have been the first book acquired by the University of Michigan after it moved to Ann Arbor in 1837. I learned this in an article by Kevin Graffagnino in The Quarto, the quarterly publication of our Clements Library [Fall-Winter 2014]. Kevin is the Director of the Clements, one of the crown jewels of the UM. The library’s magnificent reading room with its periodic displays is an ennobling place to spend a little time, although you will have to wait until the current renovations are completed.

 Audubon

[White House copy of 1826 painting of Audubon Portrait by John Syme]

 

2.     Gulo gulo. While Audubon is best known for his birds, his work also extended to mammals and included the Viviparous Quadrupeds of North America, produced in 1845-48. The Quarto, mentioned above, included an image of a wolverine from the Quadrupeds (shown below). A miniscule number of wolverines still exist in the lower 48 states, but their Darwinian niche is contracting and it is unlikely that you or I will ever see one in the wild. Of note, a wolverine was spotted in Utah at a nocturnal baited camera station last summer. Kevin’s article says: “By one account, Ohioans were responsible for pinning the name ‘wolverine’ on Michiganians, claiming that they shared the animal’s ill temper and greedy nature.” Buckeyes can be relied upon for charming perspectives of their northern neighbors. 

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Audubon’s wolverine

 The wolverine (Gulo gulo) is the largest land-dwelling species of the weasel family (Mustelidae). They have weights generally of 20-55 pounds but males have been found as large as 71 pounds. Their fur is thick and oily, making it very hydrophobic and resistant to frost. Like other mustelids their anal scent glands are very pungent. Aggressive hunters and voracious eaters, wolverines are extremely rare in Michigan outside of the Big House. The skull and teeth are the most robust of carnivores their size, allowing them to eat frozen meat and crush large bones. Gulo comes from the Latin term for glutton.

Wolverine

[National Park Service photo in Wikipedia. Taken in 1968]

Wolverine brown

[Wikipedia Commons, author Zefram, 2006]

 Wolverine ranges

[Wolverine ranges – Wikipedia]

 

3.     Linnaeus, nomenclature and humanity’s obesity. The identification of the wolverine as Gulo gulo is a convention of biologists that traces back to Carl Linnaeus in the 18th century (1707-1778). This Swedish physician got his professional start with a medical practice that rested heavily on its urological aspects and provided him the opportunity to initiate an academic career in Uppsala at the university where he developed his enduring nomenclature system. His university remains one of great institutions of worldwide academia.

Linnaeus

Returning briefly to Gulo gulo, Linnaeaus never anticipated modern molecular biology, but ironically GULO also turns out to be L-gulonolactone oxidase, an enzyme that makes the precursor to Vitamin C in most living creatures although not Homo sapiens. GULO is nonfunctional in Haplorhini (namely us dry-nosed primates) as well as some bats, some birds, and guinea pigs. Loss of GULO activity in primates occurred around 63 million years ago when they (we) split into wet-nosed and dry-nosed suborders (Strepsirrhini and Haplorhini). It has been speculated that the critical mutation leading to loss of GULO production benefited survival of early primates by increasing their uric acid levels and enhancing fructose effects leading to fat accumulation and weight gain. (Johnson et al. Trans. Am Clin Climatol Assoc. 121:295, 2010) The human susceptibility to scurvy thus is a likely side effect of one of the critical evolutionary steps in the making of modern man. This amazing thought leads back to the University of Michigan and our beloved colleague Jim Neel, the founding chair, in 1956, of our Department of Human Genetics, that I believe was the first in North America, if not the world. Towards the end of his life, Jim often showed up for lunch in our medical center’s cafeteria, always toting his old well-traveled knapsack, and we had a number of provocative conversations on such matters as the biology of morality. Johnson refers specifically to Jim’s landmark “thrifty gene” paper of 1962 [Am J Hum Genetics. 1962;14:353-62] wherein Neel suggested that genetic adaptation of our primate ancestors to famine may have left modern day humans with an increased risk for obesity and diabetes when foods became plentiful. Johnson notes that while the thrifty gene hypothesis was initially well received “the inability to identify the specific genes potentially driving this response has reduced enthusiasm for the hypothesis.” Johnson’s 2010 paper revisits Neel’s hypothesis and argues that at least 2 critical mutations led to our genetic adaptation to famine: the silencing of genes necessary for Vitamin C synthesis and for uric acid degradation. These two “knock-outs” enhance the effect of fructose in increasing fat stores.   

 

 4.     Universities. The durability of Linnaeus’s university is no fluke. Darwinian forces have kept universities in play since their origin in the Middle Ages, and since then even grown their relative effect in society. When you think about it, it seems that universities are the only truly durable organizations that are legitimately here “for tomorrow.” A modern academic, David Damrosch, demonstrated this durability by quoting a study from the Carnegie Council, so permit me to repeat his observation. “A report by the Carnegie Council in 1980 began by asking how many Western institutions have shown real staying power across time. Beginning with 1530, the date of the founding of the Lutheran Church, the authors asked how many institutions that existed then can still be found now. The authors identified sixty-six in all: the Catholic Church, the Lutheran Church, the parliaments of Iceland and of the Isle of Man – and sixty-two universities.” [Damrosch D. We Scholars. Changing the Culture of the University. Harvard University Press. 1996. p. 18] This is a powerful observation. For all their annoying features (medieval hierarchy, guild mentality, ecclesiastical titles, indentured work force, elitism, resistance to change, decentralization) universities function primarily to educate the next generation and advance knowledge.

 

5.     Named lectures. William J. Mayo, a graduate of the University of Michigan Medical School in 1883, left us $2000 as “a perpetual endowment for a yearly Mayo Lecture on some subject connected with surgery.” So that the fund could grow, he gave the first two lectures himself (1924 and 1925) and had his younger brother Charlie (a graduate of Northwestern University’s medical school in 1887) give the third lecture. Except for 1929, 1930, and 1945 the tradition has been continued. Reed Nesbit was the speaker in 1968. This year our colleague and friend Skip Campbell gave a superb talk called “From volume to value: charting a course for surgery.” He discussed our incipient brave new era wherein payments to health systems and individual physicians for services will disconnect from clinical volume alone (which is easily measured and indisputable) to parameters of quality and value (which are not so indisputably measured).

 Skip - Mayo Lecture

[Skip Campbell]

 

6.     Dick and Norma Sarns, friends and neighbors, have impacted our world and local community beyond easy measure. The impact of their company in Ann Arbor, Sarns Inc., innovator and producer of heart lung machine technology, has been incredible. The Sarns device was the one used by Dr. Christian Barnard in 1967 for the first human heart transplant. Other Sarns devices followed and the company was acquired in time by 3M and is now owned by Terumo Corporation. Cardiac rehabilitation became the next focus of Dick and Norma with their next company, NuStep, Inc. As benefactors to our community through the Ann Arbor Area Community Foundation, the University of Michigan, and numerous other nonprofits, the Sarns family has been uncommonly generous with astute focus on building a better tomorrow. The Sarns story is now permanently embedded in the  larger University of Michigan narrative in the Sarns Professorship in Cardiac Surgery. The choice of Rich Prager as the inaugural Sarns Professor is fitting. You may recall that Rich gave a magnificent Chang Lecture on Art and Medicine for us in 2013. You can revisit the  talk in his subsequent JAMA article on the murals of Henry Bethune (JAMA: PN Malani, RL Prager, “Journey in Thick Wood: The Childhood of Henry Norman Bethune”, JAMA, October 8, 2014, Volume 312.) Endowments such as the Sarns Professorship will allow the University of Michigan Medical School and Health System to recruit and retain the best of the best in academic medicine to teach the next generation, to discover new knowledge and technology for tomorrow, and to do these in the milieu of our essential deliverable – kind and excellent patient care.

Sarns  Rich Prager

[Top: Dick & Norma Sarns. Bottom: Richard Prager]

 Prager:Sarns

[Standing ovation for Rich Prager]

 

7.     Next week we will recirculate 3 three existing urology professorships in a ceremony that is long overdue (June 10 at 4 PM in the BSRB Auditorium). The Valassis endowment, originally given to Jim Montie by George Valassis, has grown enough to be split into two independent professorships. Ganesh Palapattu will be installed as the George and Sandra Valassis Professor, previously held by David Wood. Khaled Hafez will receive the George Valassis Professorship, previously held by Jim Montie. Julian Wan has taken over the Nesbit Professorship, occupied up till recently by Ed McGuire. These professorships will continue in perpetuity. These conjoined celebrations of the past and investments in the future will exist as long as the University of Michigan stands. We will need more endowed professorships here in Ann Arbor if we are to remain at the top of the game as a leader and one of the best in academic medicine as federal and clinical funding of medical education and research continue to slip.

 

 8.     The American Urological Association met in New Orleans this mid-May, having last convened in the Crescent City in 1997. University of Michigan faculty and residents had well over 100 abstracts, posters, podium sessions, and panels in addition to dozens of committee meetings. While it is impossible to even mention but a fraction of these, the MUSIC collaborative initiated by Jim Montie, deployed so excellently by David Miller and now assisted so well by Khurshid Ghani, was a highlight. This collaborative has brought many urologic practices and other urology centers outside the UM to podiums at the AUA in the interest of improving urologic care and practice. The quality, value, and safety of health care cannot effectively be managed centrally by government, industry, or national organizations such as the American Board of Medical Specialties. These attributes of excellence must be played out at the bedsides, clinics, operating tables, hospitals and in the offices of committed practitioners. Lean process believers would say that improvements in complex systems are most efficiently and effectively recognized and tested in the workplace, at the “Gemba” (lean process engineering terminology for workplace). Just as central management of a nation’s economy failed in the Soviet Union, central regulation of quality, safety, and “value” is a doomed experiment. Collaboratives such as MUSIC, built on trust and a desire to improve patient care, work best at the local and regional levels. An educational and social reception at the AUA showcased MUSIC and David Miller challenged the group to extend its work beyond prostate cancer to other urologic conditions. Walking through the main hallway of the giant convention center at the AUA meeting I kept seeing Toby Chai and Ganesh Palapattu on the video screen in the Rising Stars display. Michigan had a heavy presence at the AUA again this year.

 

9.     Our Nesbit Reception hosted more than 130 alumni, friends, faculty, and residents. For me the Nesbit Society events are high points of the year. We held this event at the 100 year-old Le Pavilion Hotel. Although hit hard by Katrina in 2005, Le Pavilion took in many of its employees with their families and pets in the wake of the devastation, yet was back up and running as a hotel by December of that year. The social part of a profession, especially a profession as social as medicine, is an essential part of its substance and pleasure and the Nesbit Society serves this function well. We had a large contingent from Denmark and the University of Copenhagen including Jens Sönksen and his daughter Louise who was a little girl when they lived in Ann Arbor. Barry Kogan, Bart & Amy Grossman, Marty & Anne Sanda, Kathleen Kieran, and our contributions to the Northwestern urology program (JO DeLancey, Diana Bowen, & Drew Flum) were on hand. So too were Sarah Fraumann and Jackie Milose who will both be doing reconstructive urology for the University of Chicago but at polar ends of the city. Stephanie Kielb of course is in the middle of the city on the Northwestern faculty. Jill Macoska was back from Boston and Bunmi (E. Oluwabunmi Olapade-Olaopa) was the most distant traveler, hailing from Ibadan, Nigeria. Many other former students and friends joined our faculty and residents for a lovely evening that Mike Kozminski and Julian Wan put together with Sandy Heskett and April Malis. Our next Nesbit event will be in the autumn (October 15-17), deep in the midst of football season and we have great expectations for our pigskin wolverines. With a new coaching staff on the scene we can well understand the need to have put aside our annual prostate cancer fund raiser, the Michigan Men’s Football Experience. It must be “first things first” for Coach Harbaugh’s team this inaugural year. While fund raisers come and go, our work in the Medical School and Health System remains nonstop without seasonality. Urologic research at Michigan continues to progress, with a number of exciting findings and technologies in play that will be discussed in upcoming departmental What’s New communications.

 Danes Jens & daughter

[Above-Danish contingent: L-> R Stefan Howart from Coloplast, Peter Oestergren, Lasse Fahrenkrug, Eric Halvarsen, André Germaine, Jens Sönksen. Bottom: Jens & Louise]

 Barry & Bart Marty & Cheryl

[Top-Barry Kogan Chair at Albany, Bart Grossman from MD Anderson; Bottom-Lindsey Herrel, Cheryl Lee, & Marty Sanda Chair at Emory]

 Osawa NPR ladies

[Top–Takahiro Osawa, Noburo Shinohara, Takahiro Mitsui; Bottom-Lindsey Cox, Yahir Santiago-Lastra, Anne Cameron]

 Alon, PAs, Jacuqi

[Alon Weizer, Jackie Milose, Mary Nowlin, Liz Marsh]

 Bonmie

[Bunmi Olapade-Olaopa, Peter Knapp, Quentin Clemens]

 

10.    It is worth reflecting upon telltale signals that we either pick up or miss. On this particular day in 1981 the Morbidity and Mortality Weekly Report of the Centers for Disease Control and Prevention reported that five people in Los Angeles, California, had a rare form of pneumonia seen only in patients with weakened immune systems. At the time this observation was a matter of only faint curiosity to most physicians, and of even less interest to the public at large until it turned out, in retrospect, to have been the first recognized cases of AIDS. In the crowded bandwidth of everyday clinical life, narrow subspecialty focus, and the administrative hassles of the practice of medicine it is important to keep a deliberate open mental channel tuned to the greater environment of healthcare and science. Many telltale signs that presage tomorrow surround us and one wonders what telltale signals we are missing amidst today’s noise and summertime moments.

May flowers [Lilacs in front of old Mott]

Upcoming events: Residents graduation dinner. Triple professorship installation. Chang Lecture on Art and Medicine Thursday July 16 – Dr. Pierre Mouriquand Professor Claude-Bernard University, Lyon, France: “Slowly down the Rhône: the river and its artists.”

 

Thanks for spending time on “Matula Thoughts” this month.

David A. Bloom