Spring and all

DAB What’s New Apr 6, 2018

Spring and all

3476 words

 

One.

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

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

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

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

 

Two.

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

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

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

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

 

Three.         

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

[Above & below: morels]

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

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

 

Four.

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

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

 

Five.

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

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

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

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

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

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

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

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

 

Six.

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

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

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

 

Nine.

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

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

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

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

 

Ten.

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

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

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

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

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

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

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

Why on the evidence of pictures is everything important?

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

 

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

Thanks for reading Matula Thoughts this April, 2018.

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

 

Marginalia

DAB What’s New Mar 2, 2018

 

Marginalia of sorts
3732 words

 

One.

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

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

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

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

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

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

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

 

Two.

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

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

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

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

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

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

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

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

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

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

 

Three.

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

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

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

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

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

 

Four.

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

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

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

 

Five.

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

 

Nine.

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

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

 

Ten.

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

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

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

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

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

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

 

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

January 5, 2018

DAB What’s New Jan 5, 2018

New year thoughts
3899 words

 

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

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

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

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

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

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

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

 

Two.

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

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

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

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

 

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

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

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

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

 

Four.

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

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

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

 

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

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

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

 

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

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

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

 

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

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

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

 

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

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

 

Nine.

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

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

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

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

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

 

Ten.

 

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

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

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

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

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

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

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

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

 

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

 

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

Dancers and Michigan’s third century

Matula Thoughts Sept 1, 2017

3866 words
Dancers & Michigan’s third century

One.

Summertime play draws to an end and work comes into sharper focus this September, as the University of Michigan enters its third century. Medical education’s academic season has been well underway for 2 months as now the rest of the University of Michigan comes back on line and takes up the challenge of examining the world anew. Autumn academic meetings lie ahead and our faculty become traveling salesmen for their ideas. History has shown that many big ideas in urology have come from Michigan and we anticipate many more are ahead. Nesbit urology alumni will reconvene in Ann Arbor this month for a scientific meeting and see the Air Force Academy play Michigan in football. [Above: Jacob Lawrence. Play, 1999. © 2017 The Jacob and Gwendolyn Knight Lawrence Foundation, Seattle / Artists Rights Society (ARS), New York]

Individual views of the world are shaped by one’s lenses and frames, literally and figuratively. Bob Uzzo, our Nesbit visiting professor this month, once sent me a picture of surgical loupes belonging to legendary Michigan Urology alumni, Ralph Straffon and Bruce Stewart, who had brilliant careers at the Cleveland Clinic. Crisp block letters identify the owners so we know who owned each one, but can only guess how the world looked to either of them. These two remarkable Nesbit trainees impacted hundreds of thousands of patients, thousands of students, and hundreds of trainees. They added to the progress of urology worldwide and both men cherished their Michigan origins and wore their Block M’s proudly. I was lucky to have known Ralph, but never met Bruce. Their photographs hang on the wall outside my office [Above glasses; below Ralph in center, Bruce upper left]. David Miller profiled Ralph for the Bulletin of the American College of Surgeons. [Miller DC, Resnick MI: Ralph A. Straffon, MD, FACS, 1928-2004, remembered. Bull Am Coll Surg 89:32, 2004.]

 

Two.

Block M’s. Pictures on our walls bring the past into focus on a daily basis and as you walk from the Main Hospital to the Cancer Center you can see the Block M on the Medical School diplomas, first as a font and later as a symbol. The class of 1861 (below) is the first in the lineup. No pictures of previous classes, going back to our origin in 1850, seem to exist. (A fire in 1911 destroyed the Medical School building with some of the original early pictures.) In 1864 an M-font vaguely resembling a block M is evident in the word “Michigan.” The first typical Block M (with serifs) appears in letters in the picture title, Departments of Medicine and Surgery in 1881. This occurs again in the text of 1883 and 1884, but is gone in 1885. Note that 1883 has 2 class pictures, the additional one being an informal one with the entire class sitting together. That additional picture was given by 1883 class member W.F. Mills to classmate William Mayo years later, in 1936.

The Block M became a deliberate symbol or logo in the Medical School 1923 class picture, with 29 faculty portraits contained within an M outline (below). Three other faculty (President Burton, Emeritus President Hutchins, and Hugh Cabot who was simultaneously dean, chief of surgery, and solitary urologist) share space outside the M shape and under the center.

The Block M tracing features faint extensions at the bottoms of the letter, called serifs, with squared edges as “blockish” as the M itself. Additional “side” serifs adorn the top outside portions of the vertical limbs of the letter. This style of serif is called a square or slab serif and it continued in subsequent class pictures, although 1928 and 1929 offered oblique views of the Block M. The frontal view was restored in 1930, the year Cabot was fired by the regents (February 11). The 1931 picture was significant for urology including both Cabot and his former trainee Reed Nesbit, the sudden head of urology. Curiously, Cabot’s picture remained even in the 1932 picture. His firing left the Medical School without a dean until 1935 when Albert Furstenberg was appointed. Block M with serifs continued through 1944, although with minor variations including one oblique reversion in 1935. Two 1943 class pictures feature separate classes, reflecting the intensified medical education during the war effort. The 1945 Block M has short and thin slab serifs.

 

Three.

A 22-year run of Block M’s with serifs ended in 1946 when the shape simplified to a simple, unadorned Block M outline, sans serifs, containing 33 faculty including Nesbit within the logo.

No 1947 picture is present on the wall. A Block M with serifs returns in 1948. The 1949 picture has no Block M insignia, font, or outline whatsoever. Dean Furstenberg is present and the faculty include Nesbit now with some gray hair. A variant Block M with serifs is present in 1950 and 1951, and now the dean’s name is spelled “Furstenburg.” A sans-serif Block M outline reappears in 1952 including Nesbit again. The traditional Block M outline with serifs is restored in 1953, 1954 (the dean is back to Furstenberg), and 1955. The UMMS lists Albert Carl Furstenberg as dean 1935-59, so the variable spelling is odd. Interestingly, from the urology perspective, junior faculty member Bill Baum, is present in 1953 and again in 1954 then with Jack Lapides. Narrow and tall serifs adorn the Block M outline in 1956 with “Furstenburg” again, but the 1957 picture oscillates back to a sans-serif Block M with Furstenberg and faculty again in the M-shape outline. Serifs returned in 1958. Lapides represented the Section of Urology on his own in 1957 and 1958.

The Block M outline vanished in 1959, replaced by a small filled-in Block M logo over the year. This unusual picture shows no faculty except for President Hatcher and Dean Furstenberg among the medical students. The 1960 picture has a sans-serif Block M symbol, but as in the previous year no pictures within the logo. Nesbit returned that year among 26 faculty shown with the class, plus the university president, Dean Furstenberg, emeritus dean, 2 assistant deans, and one administrator. A solid filled-in black Block M logo is present in 1961, but the picture contains no faculty. Redundantly, that year, the class officer pictures show those students a second time. The same format repeats in 1962. Faculty return to the picture in 1963 but only 42 (presumably only senior ones) plus a non-faculty administrator within a Block M sans-serif, that repeats in 1964 with faulty including Nesbit. That pattern persists in 1965 with 27 faculty including 2 “class mentors” and some chairs. Also present are President Hatcher, the hospital administrator, and an assistant administrator. Nesbit is missing again.

Since 1966 each picture features a fairly typical Block M outline with slab serifs and faculty embedded the letter. Nesbit was back in ’66 but looks older and returns in 1967 for his last picture, gone finally in 1968, the year of his retirement. Lapides appears as section head of urology in 1969, but isn’t pictured again. The picture format has remained relatively stable since then, although as faculty grew to over 2500 by now, general faculty pictures were replaced by dean’s office faculty and chairs.

With the recent expansion of Michigan Medicine’s footprint and regional affiliations the Block M has undergone tweaking and constraints, reportedly to maximize its effect. Articles in the Michigan Daily by Austen Hufford (October 20, 2014) and Tim Cohn (March 28, 2017) explain the evolution of the maize-colored Block M from an 1888 football team photo and 1891 team uniforms to its present proxy for the larger University of Michigan. Michigan’s branding blossomed under athletic director Don Canham, as reported by the late great sports writer Frank Deford in Sports Illustrated in 1975. [Deford. No death for a salesman. Sports Illustrated. July 28, 1975]

[Above: instructions on use of the University of Michigan logo]

 

Four.

West Shore Urology. The Block M will extend to Muskegon and the West Shore Urology (WSU) practice this fall. Started in 1972 by Thomas Stone (retired in 2000) the practice now consists of Kevin Stone (son of Thomas), Joe Salisz, Jennifer Phelps, Brian Stork, and Adam Walker (in Alaska at the time of picture) who join us as Clinical Assistant Professors of Urology as their practice becomes a UM ambulatory care unit. WSU is a high-level practice with philosophical commonalities to UM and strong ties, particularly through the Michigan Urological Surgical Improvement Collaborative (MUSIC) run by David Miller and now Khurshid Ghani. We will learn how to collaborate at a significant distance. Lisa Thurman is the PA at WSU.

Joe, Brian, and Kevin trained at Beaumont, and Jessica at Henry Ford, institutions populated by Nesbit alumni including Ananias Diokno, Jay Hollander, Evan Kass, and Hans Stricker. Adam Walker trained with Nesbit alumnus Barry Kogan at Albany Medical Center. Adam, a Hillsdale College and University of Minnesota Medical School graduate, comes from Elmendorf-Richardson Joint Base in Alaska where he was Chief of Urology, a position formerly held by our Nesbit alumnus David Bomalaski. Dave, by the way, remains in practice in Anchorage as the only pediatric urologist in the state and in the entire Indian Health Services system. The WSU team staffs Hackley Hospital, Mercy General Health Partners, Gerber Hospital in Fremont, North Ottawa Community Hospital, and Muskegon Surgical Center. Their diverse skills and perspectives will enlarge our Department.

 

Five.

American artist Jacob Lawrence (1917-2000) was born 100 years ago (September 7). I first saw his work at the Phillips Collection in Washington, DC when in town for a meeting of the American Academy of Pediatrics Section on Urology. His 60-panel Migration Series, funded by the Works Progress Administration and completed in 1941, illustrated the story of the Great African-American Migration from the rural south to the urban north, beginning around 1910. Lawrence worked on the paintings more or less simultaneously to maintain a uniform stylistic sense, he called “dynamic cubism” and considered the work a unity rather than 60 individual paintings.

Fortune Magazine in 1941 published 26 paintings from the series. Ironically, the paintings are now divided between the Phillips Collection (odd-numbered), where I first saw Lawrence’s work, and the Museum of Modern Art in New York (even-numbered). In 2015 and 2016 the split collections were merged and exhibited as a complete set at each museum before returning to their previous homes. Three-dimensional reconstructions of this work form the introduction to the current Kathryn Bigelow film, Detroit. Lawrence told other stories in collections of paintings featuring Harriet Tubman, Frederick Douglass, John Brown, Toussaint L’Ouverture, and a set called The Builders Series.

[Photograph above: Jacob Lawrence, Peter A. Juley & Son Collection, Smithsonian American Art Museum J0001840. Original photograph by Geoffery Clements. Image courtesy of the American Federation of Arts records, 1895-1993 in the Archives of American Art, Smithsonian Institution. Below: John Brown as surveyor in The John Brown Series. © The Jacob and Gwendolyn Knight Lawrence Foundation]

 

Six.

Throughout most of human history health care was delivered by single individuals. Presumably starting out in clans and villages our predecessors in healthcare accumulated healing skills through practice of their arts. Midwives, shamen, herbalists, and the stone doctors mentioned by Hippocrates, specialized in skills. By mid-16th century specialists such as internists, barber-surgeons, and apothecaries were assembling in guilds. Subspecialization reached full display in mid-20th century, when most physicians sought special knowledge and skills based on organ systems, technologies, age groups, or sites of service such as emergency departments and ICUs. The career-defining piece of medical education shifted from medical schools to graduate medical education (residency training) now involving over 100 areas of focused practice, often taking as much time or more than medical school years. The downside of this plethora of specialties is a complex clinical terrain in which patients shuffle among specialists, responsibility is diffuse, hand-offs incur errors, patient satisfaction sinks, and costs soar.

It is natural that arborization of medical skills is countered by nostalgia for omnipotent physicians to take complete care of patients or at least “quarterback” the specialists. This notion of primary care vs. specialty care, however, is more a political distinction than an epistemological one. The idea that everyone should have a “primary” caregiver who will identify specific needs for “specialty care” in patients and make proper referrals (administratively approved by third parties) is attractive, but the reality is that many, if not most, patients needing something specific, identify that need themselves – broken bones, eye trouble, urinary infection, chest pain, etc. – and find care through an emergency department or direct referral to specialists. The modern dilemma of coordinating health care teams, epistemologies, funding mechanisms, education, research, public policies, markets, while maintaining equity is acute. This is the arena of health services research.

Our Dow Health Services Research Symposium is in a bye year, and will hold its 4th meeting in 2018, highlighting our best faculty and resident work and bringing notable young urologists from across the country to similarly showcase their academic wares. Above you see last year’s symposium where Chad Ellimoottil, Michigan Urology Assistant Professor, highlighted Avedis Donabedian, Michigan’s great founder of health services. I first heard Donabedian’s name through Jim Montie and David Miller who gave me the classic 1966 paper. [see Berwick and Fox, Milbank Quarterly 94: 237, 2016] Health service researchers frame clinical problems one way, urologists view them another way, patients have personal points of view, and family members have their own perspectives. All those visions matter, although that of the patient usually dominates for it is on the patient’s behalf that society marshals the resources of treatment.

 

Seven.

Responding to thoughts on secularism and sectarianism in these pages last month, my friend David Featherman – Professor Emeritus of Sociology, Psychology, and Population Studies and former Director of Michigan’s Institute for Social Research – took my comments to a deeper and more significant level, writing:

“Of course, the most common antonym of secular is sacred, although partisan or sectarian appear in some thesaurus sources, as you note. As a general mental puzzle for me these days I wonder if our secular society, for all its other benefits you note, has verged, in some instances or quarters into sectarianism – in the sense of illiberal, intolerant and perhaps even partisan … Certainly, what I point to is not religious sectarianism, although one might admit to a quasi-religious sectarianism …
Those docs-to-be [referring to the White Coat Ceremony], touching patients with their stethoscopes, strike me as potentially moving beyond the non-spiritual or secular into a realm of human interaction not entirely bound by rationality and reason or lacking in the stuff of human compassion or failing to acknowledge something like a ‘mystery’ in life and death … What strikes me as I write is that the white coat might symbolize one of the larger dilemmas of our time, namely, how to draw upon the sacred and the secular as complementary resources …
If zealots … only can see opposition, in archly incommensurate terms, we shall fail to build that cosmopolitan, tolerant but at the same time spiritually, morally, and ethically grounded world. Without the latter resources, an exclusively secular world of wholly liberated individuals can easily lose its bearings to entropy. Those young docs in training have extraordinary opportunity to teach us how to achieve a more complementary cosmopolitanism, day by day, patient by patient.”

David’s point, in a nutshell, seems to be that we cannot isolate secular professionalism of health care from a notion of the sacredness of human life and morality. This veneration transcends specific religions, deities, or other schools of belief, but it is a sacredness that the secular world needs to contain, even if this seems somewhat paradoxical. Lacking this, Professor Featherman rightly professes, a secular society and its cosmopolitan world of nations, religions, markets, universities, politics, and corporations, spin out centrifugally and dissolve into entropy.

 

Eight.

The eclipse last month brought a moment of cosmic uncertainty to the uninformed, although astronomers profess that the occurrence was totally predictable and certain, occurring completely over the continental United States. [Above picture from Hinode Solar Observatory Satellite JAXA/NASA. August 21, 2017.] My colleague Philip Ransley, who has split his career between pediatric urology and chasing the moon’s shadow, gave a lovely talk on lunar eclipses when he received the Pediatric Urology Medal from the American Academy of Pediatrics in 2002:

“There is a beautiful rhythm in moonrise and rhythm in sunset. But there is nothing to compare with standing high on the Bolivian Altiplano in the center of the cone of the moon’s shadow with sunset all around and the eclipsed sun hanging in the darkness. Here, the majestic progression of time is played out before your eyes. An eclipse is quite an extraordinary coincidence. The sun is 400 times larger than the moon. By coincidence it is exactly 400 times farther away, and so the moon just covers the sun. But beware! We live in special times. The moon is moving away from us by a few centimeters each year. That is more than a meter further away than it was when I started coming to AAP meetings, and after only 2,000 million more annual meetings the moon will have moved so far away it can no longer cover the sun.” [Ransley. Chasing the moon’s shadow. J. Urol 168:1671, 2002]

This geometric coincidence is a cosmic rarity of time and space. Science writer George Musser wrote: “In all the hundreds of billions of our Milky Way galaxy, few, if any, are likely to produce total eclipses like ours.” [NYT Aug 6, 2017. The great American eclipse of 2017.] Rare moments of eclipses once terrified our ancestors, jeopardizing their routine predictability of day and night. Mark Twain’s 1889 book, A Connecticut Yankee in King Arthur’s Court, tells of an engineer who, after a head injury, finds himself in 6th century England and convinces people he is a magician by using the tricks of modern knowledge, such as predicting the eclipse of 528. Edmund Halley in 1691 applied the name Saros, from an 11th century Byzantine lexicon, to the eclipse cycle of 6585.3211 days that predicts when nearly identical eclipses occur. Halley’s appropriation of the name may be technically inaccurate with respect to the number, but it has endured. The celestial dance of Sun and Moon, from our point of view as Earthly audience, produces spectacular moments of eclipse when the two bodies seem to become one. Knowledge transforms those coincidences from terrifying episodes of uncertainty to predictable occasions of beauty. [Above: lunar eclipse diagram, Tom Ruen. Wikimedia, public domain.]

 

Nine.

A transatlantic collaboration between Ann Arbor and Copenhagen, initiated 23 years ago by Dana Ohl and Jens Sønksen (above) culminated 2 years ago in Denmark with a conference branded as CopMich, and reconvened here in Michigan for 3 days last month with 50 excellent talks from junior and senior faculty of both institutions, plus our residents and fellows (below). Dana and Jens plan to continue this on a 2-year cycle, offset with our biennial Dow Health Services Research meeting. Our Andrology Division under Dana Ohl has grown to 4 clinicians including Jim Dupree, Miriam Hadj-Moussa, and Susanne Quallich Ph.D. (nursing). Jens spent a year working with Dana in 1994 and has maintained close ties with Michigan Urology. Our new residents room is named for Jens.

CopMich has expanded beyond andrology to include stone disease, voiding dysfunction, pelvic pain, and robotic oncology surgery with speakers from our department and the Department of Urology at Herlev and Gentofte Hospital and the University of Copenhagen, where Jens is Professor and Chair. Guest speakers were Manoj Monga, Director of the Stevan Streem Center for Endourology and Stone Disease at the Cleveland Clinic as well as the American Urological Association Secretary, and Chris Chapple of the Royal Hallamshire Hospital in Sheffield UK and Secretary General of the European Association of Urology. [Below: Manoj and Chris]

Michigan’s own celebrities spoke at CopMich program as well. Ed McGuire, emeritus professor and chief of urology (1983-92) and John DeLancey Professor of OBGYN have virtually defined the intellectual and clinical terrain of female pelvic medicine and pelvic floor neuroanatomy. Dee Fenner, like John, is also a joint faculty member of Urology and esteemed throughout the world. [Below: McGuire, Fenner, DeLancey]

The meeting, offering 15.75 CME credits, was underwritten by both academic units as well as ReproUnion and the Coloplast Corporation. Stig Jørgensen (below) represented ReproUnion and gave an excellent presentation on its funding mechanisms in Europe.

The Danish contingent was superb (partial contingent below) and, after all, there is nothing like a Dane (apologies to Rogers, Hammerstein, and South Pacific).

 

Ten.

My daughter Emily is an Irish literature scholar, so any mention of WB Yeats is likely to catch my attention, especially in an administrative meeting. This happened recently when Marschall Runge brought Dr. Fionnuala Walsh, former senior vice president of global quality at Lilly, to his regular meeting with the department chairs to describe the company’s quality journey to operational excellence. Her presentation perked me up with a reference to Yeats, specifically the last 2 lines in his 1928 poem Among School Children:

“O body swayed to music, O brightening glance,
How can we know the dancer from the dance?”

Novices like me can hardly guess exactly what Yeats had in mind with this thought, beyond the obvious conflation of performer and performance, but that’s the beauty of art in that one’s personal experience as the viewer or reader is where meaning is ultimately ascertained. Yeats also reflected on dance in other works, notably Sweet Dancer, a poem begging the audience to let the dancer “finish her dance.” [EC Bloom. W.B. Yeats’s Radiogenic Poetry in The Wireless Past. Oxford University Press. 2016] Sweet Dancer was first published as a radio play in 1937, a time described as Yeats’ “second puberty.” Yeats’s life, like most, intersected with urology and for him the coincidence most famously was his Steinach operation in 1934. [MA Kozminski, DAB. J Urol. 187:1130, 2012]

That metaphor of unity between art and artist surfaced again recently in a JAMA article by Kimberly Myers called The Paradox of Mindfulness: Seamus Heaney’s “St Kevin and the Blackbird.” [JAMA. A Piece of My Mind. 318:427, 2017] Myers reflected on the challenging impact of fatigue on a person’s attentiveness to responsibility and compassion and links the allegory of the medieval monk to the modern health care provider.
“One might say of the physician what St Anthony says of the monk: ‘The prayer of the monk is not perfect until he no longer recognizes himself or the fact that he is praying.’ … commitment to patient-centered medicine is noble, and it is arduous. And, as is true with any other clinical skill, perhaps it is only with years of practice and continual commitment to being one’s most authentic self in the work he is called to do that it becomes second nature, part of his very body, blood, and bones. Perhaps we are indeed most mindful when we are least aware of being mindful – to borrow a beautiful phrase from another Irish Nobel laureate, W.B. Yeats, when we no longer ‘know the dancer from the dance.’”

This idea brings me back to last month’s reflection on performance and the aspiration of going beyond mere competence to achieve excellence in one’s work. As medical faculty perform the work and study of health care while educating their successors, the moments of our performances are quantum bits of education for those who learn from us. Our best clinical and academic performances can inspire a future physician for a lifetime.

When we fall short we hope our observers have compassion for our human frailty, but that they are challenged to surpass us in their work. The extraordinary emergence, when a dancer achieves unity with a dance, is the very art of medicine that glues us together and inspires those who follow, now in the third century of the University of Michigan.

 

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

Matula Thoughts July 7, 2017

DAB What’s New July 7, 2017

 

The Fourth, stories, & art

3789 words

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

Flag

One.              

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

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

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

Fireworks2

[Fireworks, Barton Hills 2017]

 

Two.

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

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

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

 

Three.

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

Ian & Ted

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

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

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

 

Four. 

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

Point counterpoint

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

 

Five.

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

Fire_ants_01

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

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

 

Six.

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

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

400px-RoswellDailyRecordJuly8,1947

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

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

 

Seven.          

Lapides copy 3

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

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

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

 

Eight.

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

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

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

Bronze star

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

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

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

 

Nine.

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

 

Ten.

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

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

Gibbes

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

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

AAAF 2016

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

 

Thanks for reading What’s New and Matula Thoughts.

David A. Bloom

University of Michigan, Department of Urology, Ann Arbor

Matula Thoughts May 5, 2017

DAB What’s New May 5, 2017

Ideas, evidence, & anniversaries
3914 words


 

One.

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

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

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

 

Two.

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

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

 

Three.

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

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

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

 

Four.

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

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

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

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

 

Five.

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

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

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

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

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

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

 

Six.

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

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

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

 

Seven.

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

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

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

 

Eight.

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

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

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

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

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

 

Nine.

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

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

 

Ten.

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

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


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


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

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

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

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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.

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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.

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[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