University of Michigan

Matula Thoughts October 3, 2014

Posted by

0

Matula Thoughts October 3, 2014

Michigan Urology Family

Aspirations, bandwidth, clinical value, & existential epidemics.

3379 words, 12 items.

1. Human FactorWith the colder and less sunny days of October at hand, it’s refreshing to come back to this aspirational symbol that the Dow Corporation developed to describe what they call “THE HUMAN ELEMENT.” This implies something unique and emergent to our species. Mankind’s days, even on the cold and dark ones, are distinguished by human aspirations that extend beyond the basic drives, common to all life forms, of survival and comfort. Those of us with health care careers are especially compelled by the more complex human drives and aspirations that Adam Smith, Scottish philosopher and pioneer economist, noted in his book The Theory of Moral Sentiments in 1759: “How selfish soever 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.” Then and now, Scotland has been an important intellectual and economic part of the British Empire, although its days within the empire nearly ended just last month.

2. Tough days. Days are getting shorter by this point in the year and we find ourselves halfway to that time in the northern hemisphere when human optimism encounters its great celestial challenge from the shortest diurnal stretch of daylight. With the calendar now in its final quarter we can tally a good measure of notable human accomplishments for 2014, although these are counterbalanced by terrible existential threats for mankind including viral contagions and epidemics of extremist sectarianism. Ebola is likely to be a game-changer for civilization and the terrorism perpetrated by fanatic groups is no less horrific, although with less capacity to become global in a matter of days. Curiously both of these threats are infectious diseases – one due to a virus and the other an infectious disease of human thought. The responses of the civilized modern world to these contagions will set the stage for 2015 and thereafter. We have dealt with game-changing infectious diseases before and can overcome these new ones as well, but not without much pain and tragedy. A TED talk by the astronomer Martin Rees filmed in March 2014 touches on human existential concerns and well worth 7 minutes of your time, leaving you with both anxiety for our ultimate fate and optimism for the potential bright side of the human element [Rees. Can we prevent the end of the world? TEDGlobal 2014].

EbolaCycle-1

300px-Filovirus_phylogenetic_tree.svg

220px-Ebola_virus_virion

[Ebola cycle, family of viruses & the actual virus – from CDC]

3. Data & information. The positive side of the 2014 ledger to date must include the Second Dow Health Services Research Symposium we held in mid-September. The meeting focused on big data and its implications for health services research. While information may be sensory, narrative, or numeric, it is the numeric information that we call “data.” Big data is the current phrase for data sets too large and complex to manage with simple calculators, tools or traditional data processing applications. Detail about our symposium is beyond the scope of today’s message, so write me if you want a CD of the proceedings. I will come back in future months to the concepts of information and data, but let me cherry-pick a few highlights of the meeting at this time. Stewart Wang presented the amazing morphomics model he built out of big data to manage patients with major traumatic injuries. He also challenged analysts to consider “what is not there” in the data – for example the critical social element behind any information.  Jason Owen-Smith explained the importance of social networks to physicians and health care. John Ayanian discussed big data in health care reform. Charles Friedman talked about “learning health systems” and analyzed the Panama Canal as a complex project requiring many forms of data integration including that of social factors, political forces, and infectious diseases. He highlighted Dr. William Gorgas, the chief sanitation officer on the canal project, as the hero of the infectious disease mitigation necessary for success. Craig Sincock, CEO of Avfuel Corporation here in Ann Arbor, showed that a passionate human element is necessary to translate data and ideas into excellent execution of any job, or in the larger success of any business or organization. He explained how context counts; no one can know everything and a team with a diverse crowd of talents on board is able to solve problems far better than a team consisting only of a single set of skills and world-views. Caprice Greenberg spoke about models of learning and new concepts of experiential “student-driven” learning for surgeons to make personal progress on the “asymptotic curve of mastery” (Daniel Pink’s metaphor). While we are focused intensely on data, and big data is a current favorite bit of jargon on the center stage, it is only its interpretation and utility to the human element that gives it meaning and makes it matter. As Craig Sincock told us, and as his company Avfuel proves, it takes enthusiasm and passion to parlay data into meaningful and great results. The symposium was superb, so feel free to take me up on the offer of a CD.

4. Pictures from a symposium.

Knowledge

[My view of the information to wisdom highway]

Miller HSR

[David Miller addressing our second HSR symposium]

Back of room

[From the back of the room]

Wang etc.

[Dave Miller, Stewart Wang, John Gore, Khurshid Ghani]

Sincock

[Craig Sincock, CEO of Avfuel, explaining how passion creates great performance from data]

Ayanian

[John Ayanian and John Hollingsworth in the Big House after Craig’s talk]

5. Bandwidth. A geek might say that soon we will exhaust the calendar bandwidth of 2014. Actually, you and I use that term equally comfortably as it has moved from the world of techno-speak to the vernacular of nearly everyone. Such is the mutability of language, bandwidth now fills an essential niche in modern life. That linguistic space was previously but inadequately filled by terms such as attention or time. We often heard statements like: “You didn’t pay attention to me” or “I don’t have time for this.” These phrases carry the intended message, but wrongly imply a social shortfall of personal needs – the attention that I need or the time that I have. We have come to discover, learning through the technology that we invented, that the real problem is physical limitation – the width of our band – namely the limited capacity of our 8-pound cerebral neuronal network to manage the ambient information.
Shannon's Gen comm system

[Claude Shannon’s diagram of a general communications system c. 1949]

6. Attention pollution. Our brains have been hardwired over hundreds of thousands of years to contend with strengths, weaknesses, threats, and opportunities in changing environments. The parameters of change, however, were finite – limited mainly to feast or famine, cold or heat, predators or parasites, rain or drought, hurricaines or earthquakes, occasional eclipses, and rare meteor impacts. People interacted in finite ways and within finite social units. Complex civilization and modern technology now offer nearly infinite possibilities of change, including interactions with thousands of unwanted friends and linked-in pals. The information available to mankind today, evidenced by the Shannon number (see Matula Thoughts May 3, 2013 on Claude Shannon at matulathoughts.org) and Wikipedia, defines comprehension. Our wireless brains, like our home wireless networks, are limited by the physical constraints of our individual bandwidths. This is especially problematic for modern health care workers, particularly in academic medical centers with triple missions. The doctor-patient relationship has grown unbelievably more complex as the essential transactions of health care, including its educational, discovery, regulatory, and financial facets, now occupy most bandwidth of patients and providers. Personal bandwidth in clinical medicine is terribly crowded and we need to strip out the nonsense that detracts from the essential transactions of patient care. Attention pollution has become a quality and safety concern. Alarms from public address systems, bedside monitors, pagers, smart phones, fire alarm testing, and beepers distract from consistent thought and focus. Federally mandated electronic record systems have further diverted attention from the patient to the keyboard and created avatars of patients made from cut and pasted scripts, dot phrases, and drop down menus that are phony models for actual authentic patients.

Crayon drawing

[again let me show this picture from Elizabeth Toll: The cost of technology. JAMA 307: 2947, 2012. © TG Murphy]

7. Screen Shot 2014-10-01 at 12.24.52 PMBig healthcare. We work in a complex and large environment that is short of physical bandwidth and attention bandwidth relative to the essential transactions of healthcare. Last month for the first time in history, our Emergency Department was so overwhelmed on one day that the clinical departments were asked to divert their emergencies to other hospitals. On many other days, it is a standing condition that our ICUs, operating rooms, and hospital beds are fully loaded such that transfers cannot be accepted or routine OR cases have to be deferred. On top of our facility overload we have to factor in the overload of individual bandwidth of health care providers by electronic medical record perversions, regulatory constraints, and all that noise around us. A new normal condition of professional attention deficit disorder is at hand. I was recently asked to bring two renal failure patients from other healthcare organizations into our system at Michigan. One pediatric patient was from another country  while the other was a local pre-transplant patient, the wife of a local business owner, and already a patient at a competing system of ours. I think I struck out on the first patient, trying with a number of calls and conversations to hand it off to others to make the connection and get it organized. Regarding the second patient, however, a single call to a colleague did the trick and brought her to UM where she now is in place waiting for next steps in her care.

In de-briefing the family, I rediscovered a few useful facts. Fact number one: most colleagues and services lines here at Michigan are reliable and even though not “hungry for new patients” they are hungry to help. Yes, our facilities and manpower are sadly insufficient for our daily clinical needs. More patients want clinic visits and more of them need operative procedures than our capacity easily allows. Faculty, at considerable personal cost, mitigate this mismatch every day. Too often it takes heroic deeds to solve trivial problems. This mismatch has existed for well over a decade, but it keeps getting worse. Why the mismatch exists is not a complex question. Our organizational structure and leadership(myself included) have not been able to match institutional capacity to accommodate daily clinical needs and seasonal variation.

8. Time. Fact number two: time is important to patients. This should hardly be a surprise, time is important to everyone. For someone facing a kidney transplant who wants to come to the UM, an entry appointment in 1-2 weeks is far more acceptable than one in 6 weeks, even if the actual transplant is not imminent. The time to first appointment for a new patient is a surrogate for “concern” or interest of the clinical service and its physicians (and by extension – “concern of the UM”). Fact number three: people appreciate preparation – and some visible evidence of preparation on the part of the clinician is another surrogate for “concern.” The husband of the second patient said they were quite satisfied with the first visit. My colleagues “squeezed” her into their busy schedules and saw her promptly. I asked what the negatives might have been with the visit (there are ALWAYS negatives – but unless we dig for them we may not understand them). Not wanting to seem ungrateful, the husband said that they liked our doctors and had enough confidence to transfer her care here. However, I could tell there were some negatives and asked what we could have done better. He said that one thing that had impressed him and his wife when visiting our competitor was that those physicians had looked at the notes and chart before they walked into the room. I confess that I haven’t always done this – my bandwidth seems to be pretty full even before I squeeze another patient onto my schedule. However, I believe I need to make this adjustment to make a semblance of introductory conversation that indicates familiarity with the issue at hand. Even cursory preparation allows me to walk in the room with necessary materials – for example if a new patient is a child with posterior urethral valves, I can walk in the room and say something like “I see from Dr. Jones’s note that your child has posterior urethral valves – and I have some reading materials on the problem for you. But first tell me from your point of view what’s been going on.” Patients usually hate to be asked: “why are you here?” (It may sound like – “Why are you bothering me?” to them.)

9. Time again. Fact number two again, we can’t overstate this: time is important. The other thing the husband reluctantly told me is that the visit took 7 hours. As a customer-oriented businessman, while very grateful to have been “squeezed in,” he thought 7 hours was “kind of” a lot more time than necessary. We have become prisoners to our systems and facilities and are not good at creating efficiency for ourselves and our patients. This is part of the so-called value proposition. I think we need to find a way to “concierge” our patients through each stage of care. At the UM we have somehow managed, through the design of our workflows and our facilities to squander time for both our patients and our providers. Other competitors, like the Mayo Clinic, long ago figured that the provider is a crucial rate-limiting factor in clinical care. So if you visit Rochester, Minnesota you see systems built and organized to maximize the efficiency of providers and maximize value to patients. Clinical value is largely a matter of time, perception of expertise, and ability to satisfy a patient’s needs. In my opinion patients want three main things: expertise, kindness, and convenience. The business school rhetoric may be that charges and true costs are key features of the value equation, but clinical value must be viewed from the patient’s perspective, which is rooted in time, perceived expertise, and satisfaction of expectations. We must find ways to mitigate these internal stresses and “self-inflicted wounds” in healthcare of our systems and mindsets because the external stresses are likely to increase.

10. Infectious diseases. Among the external stresses we face in health care are the infectious diseases that shape the world. This is nothing new, for they have shaped civilization, individual nations, and even the University of Michigan. Two diseases are of particular interest. The university began its operations in Detroit in 1817, but had to cease operations several times in the 1830s, closing its doors because of raging cholera epidemics in southeast Michigan. This instability set the stage for the relocation of the university to Ann Arbor in 1838. While cholera, a bacterial infection caused by Vibrio cholera, was transferred by ingestion of contaminated water here in Michigan, further to the south on this continent a different contagion, yellow fever, had a another means of spread. This RNA Flavivirus is transferred from person to person by female mosquitoes of the Aedes aegypti species and in severe epidemics yellow fever mortality exceeded 50%. Today, a safe and effective vaccine is available for yellow fever, and mosquito control limits the vector in much of the world. Cholera can be easily eliminated by sanitation and clean water, the very basics of civilization. Nonetheless Vibrio cholera caused the deaths of Peter Tchaikovsky, James Polk, and Carl von Clausewitiz, nearly 10,000 Haitians after the 2010 earthquake, and currently well over 100,000 a year worldwide in a world we have called civilized. Curiously, cholera was unknown in Haiti until aid workers brought in to help after the quake introduced the bacilli via poor sanitation facilities. You can read about it in an article in Science just a few weeks ago: the specific workers were from Nepal where the bacillus is endemic. [Kean. S. As cholera goes so goes Haiti. Science. 345:1266-1268, 2014] As cynics say – no good deed goes unpunished. Cholera remains a huge public health issue in Haiti – in spite of the fact that its prevention is a mere matter of keeping poop from the water and food people ingest. Currently another frightening new threat is in the news – enterovirus D-68. In this day of smart phones and other technological accomplishments of the human element, it makes one wonder why big pharma seems focused on blockbuster life-style drugs with their direct-to consumer advertising instead of looking into the biology, prevention, and treatment of our real existential threats. The same criticism can be leveled at us in universities.
300px-Cholera_bacteria_SEM  220px-Cholera [Cholera & 1919 poster]
230px-YellowFeverVirus  220px-Aedes_aegypti_bloodfeeding_CDC_Gathany  [Yellow fever virus & vector Aedes aegypti]

11. This day in history. Every calendar day has its historic overtones, some universally recognized and others obscure, but significant. Back in 1854 in Toulminville (near Mobile), Alabama, William Crawford Gorgas (1854-1920) was born on this particular day. His name is familiar to you as the U.S. Army surgeon of essential importance to the completion of the Panama Canal. Gorgas had parlayed the ideas of Walter Reed (who in his own turn had parlayed the ideas of Cuban physician Carlos Finlay) into eradication of yellow fever and malaria in Havana after the Spanish-American War in 1898. Based on that success he was appointed chief sanitation officer of the Panama Canal construction project in 1904 where he successfully implemented sanitation and mosquito control. He later became president of the American Medical Association (1909-1910) and Surgeon General of the U.S. Army (1914). He died in London on July 3, 1920 shortly after receiving an honorary knighthood from King George V. While the story of Gorgas is of interest, so too is that of the doctor who delivered him as an infant on this day in 1854.  [Picture: US Army Center of Military History. The Panama Canal: An Army’s Enterprise. 2009 p. 36. CMH Pub 70-115-1]

12. A curious coincidence. The obstetrician was Josiah Clark Nott, an obscure name today but one I encountered in recent historical studies. Yellow fever was a big problem in South Carolina, Alabama, and Louisiana, where Nott had worked during much of his career. In 1848 he wrote an astonishing paper in the New Orleans Medical and Surgical Journal entitled “Yellow Fever contrasted with Bilious Fever – Reasons for believing it a disease sui generis – Its mode of Propagation – Remote Cause – Probable insect or animalicular origin. etc.” [4:563-601, 1848] This predated the germ theory, Koch’s postulates, Semmelweis’s experiment, Lister’s antisepsis proofs, and the confirmation by Finlay and Reed that yellow fever was transmitted by a particular mosquito species. Ironically, Nott lost 4 of his own children to yellow fever within a single week in 1856 even though he had moved his family out to the country from Mobile hoping to escape an epidemic of Vibrio cholera. Nott’s enduring intellectual history was subsequently framed and marred by his misguided advocacy of polygenesis and white supremacy. Yet Nott’s legacy as a physician, like that of most physicians, is unknowable in terms of the lives he impacted as a caregiver and teacher. The lucky coincidence of Gorgas’s birth as well as the visible remnants of his patient care and teaching evidenced in a few historical documents are all that remains. As with most physicians, however, their impact on the lives of others, perhaps a cardinal motivating factor in their entry into the field of medicine, although incalculable, is a sustaining feature of civilization. We feel this fact most acutely today in the accruing numbers of physicians in West Africa who are succumbing to the effects of the new terrible epidemic that they are trying to mitigate in their patients. Regardless of our individual bandwidths or that of modern society, Ebola and other bad actors are at hand and it will be dealt with – how well we deal with them will be define us. Doctors without Borders and other international volunteers embody the better aspirations of mankind and Adam Smith’s observation that “However selfish soever….” We are hopeful that a few modern-day Gorgas’s or vaccines will turn up to stem the tide of these impeding devastations.
Ebola scene  Hn8

[NBC News DANIEL BEREHULAK / REDUX PICTURE]

 

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

David A. Bloom

Matula Thoughts August 1, 2014. Art & medicine.

Posted by

1

Matula Thoughts August 1, 2014: Art & medicine

This is the blog format of the monthly email communication called “What’s New” from the University of Michigan Urology Department.

 

 

1.  Drive home

My drive home from work in the summer is likely to occur in cheerful sunlight, even when the hour is late. A good piece of this seasonal pleasure still remains for us at the start of August. July 2014 has come to a close and with it the celebration of the Fourth, the Ann Arbor Art Fairs, and the Chang-Duckett-Lapides Lectureships of the Urology Department. Our PGY1s (interns) class of 2019 began at least five years of residency training that may easily extend by several additional years with fellowships that many of our graduates undertake. The lectureships we hold every year around this time add some formality and socialization as the new academic season of residency training commences. Andrew Kirsch of Emory University gave a remarkable Duckett Lecture on his work with magnetic resonance urography (MRU) and Kassa Darge of the Children’s Hospital of Philadelphia produced a superb Lapides Lecture on the wide scope of urologic imaging and his experience with MRU. We had excellent attendance and wonderful discussion. MRU is clearly the new IVP. Yes, it is at present much more costly, but as we saw in the discussions, a careful history and physical exam with high quality GU ultrasonography in the hands of well-trained and experienced clinicians will answer anatomic questions well enough to deal for most problems we see. In complex situations, however, the detailed anatomic and functional information from the MRU is unsurpassed. George Drach of the University of Pennsylvania presented a clear discussion of a muddy topic – the Affordable Care Act. He promised that the topic will get even muddier next year as complex add-on legislation accrues in the year ahead.

Kirsch

[Andrew Kirsch, Duckett Lecturer, with Susan Kirsch]

Duckett Drach Darge

[Peggy Duckett, George Drach, & Kassa Darge, Lapides Lecturer]

 

2.    The Chang Lecture on Art and Medicine (our 8th) was given by James Ravin, a well-known ophthalmologist from Toledo who had trained here in Ann Arbor. I first learned about him through his book, The Artist’s Eyes, which had been sent to me by Steven and Faith Brown, Michigan alumni and strong supporters of Michigan Urology. The lecture was amazing and we can mail you a CD of the lecture if you send us a note. Before Dr. Ravin took the microphone, I asked the audience: Why should a urology department care about the link between art and medicine? My answer was twofold and I’d like to repeat it here. The first reason is simply the matula. This long-standing symbol of the medical profession is the flask used for the macroscopic examination of urine. Not insignificantly that is also the name we selected for this blog. The second reason is that this linkage is hardwired in our species. Genetics and epigenetics demand this attention from us. Maybe this is a presumptive conceit, but most people believe our existence among life forms is unique and that the distinctive human condition we claim is built upon our curiosity, our creativity, and our tendency to reflect upon ourselves as well as our fellows. These traits have led to our ability to solve problems cooperatively and accomplish complex tasks like building cathedrals, performing symphonies, writing encyclopedias, or doing cystectomies and urinary diversions. Art is part of all human performances, most especially the medical arts.

Chang's

[Hamilton Chang, James Ravin – Chang Lecturer, & Dr. Cheng-Yang Chang]

 

3.    That the study of art should occur in a university is no surprise, universities are the primary stewards of the future – the human future and the global future. Universities educate tomorrow’s builders, thinkers, and citizens. They and their graduates are the primary sources of tomorrow’s ideas and inventions. No other institution in society has such a broad mandate, much less fulfilled it so well over centuries as universities. Ben Shahn, an American Artist of the second part of the 20th century, put together an essay in a book called The Shape of Content in 1960, where he specifically addressed the matter of visual art in universities, writing: “What can any artist bring to the general knowledge or theoretical view of art that has not already been fully expounded? What can he say in words that he could not far more skillfully present in pictorial form? Is not the painting rather than the printed page his testament? Will he not only expend his energies without in any way increasing the general enlightenment? And then, what can an audience gain from listening to an artist that it could not apprehend far more readily simply by looking at his pictures?” While Shahn was specific that his comments related to visual art, his point extends more broadly.

 

4.    Shahn answers his own questions in the essay, developed from lectures at Harvard College and offers two reasons why universities (and by extension medical schools and their departments) should be interested in art. First, the product of universities, educated persons, should have what he called the accomplishment of perceptivity – a necessity for tomorrow’s international citizens. His second reason is that the universities, themselves, are enriched by bringing art, he says, into the circle of humanistic studies. This point anticipates the vision that E.O. Wilson called consilience, the idea of global village of knowledge in which boundaries between fields of study are mere human conceits. Wilson contends that the most important findings for our species will be made at the interfaces and boundary waters among the fields. Shahn expands on this second point in his essay, saying that bringing art into the circle of humanistic studies serves the: “… general objective of unifying the different branches of study toward some kind of a whole culture. I think it is highly desirable that such diverse fields as, let us say, physics or mathematics, come within the purview of the painter, who may amazingly enough find in them impressive visual elements or principles. I think it is equally desirable the physicist or mathematician come to accept into his hierarchy of calculable things, … [the] nonmeasurable and extremely random human element which we commonly associate with poetry or art.” [Shahn p. 9]

 

5.    Visiting professorships are an important part of academia, bringing the best insights of established thought leaders, as well as the newer voices and controversial ideas of those who challenge the status quo. We do this fairly well at Michigan Urology throughout the year in each of the disciplines within our field. It is equally and especially important for universities to offer periodic public lectures on broad themes such as Ben Shahn provided at Harvard for general audiences on topics that offer important humanistic insights, cut across fields of study, and stimulate conversation and cultural curiosity. We try to fulfill our part with the Chang Lecture and if you missed it this year, consider holding that calendar slot next year on the Thursday of the Art Fairs. Our speaker will be Pierre Mouriquand of Lyon, France. He is an extraordinary pediatric urologist, a deep thinker, and a committed artist who paints nearly every day.

 

6.    A number of years ago I came across a wonderful statement made by the late and great Michigan faculty member and world-class physiologist, Horace Davenport. A student recalled him telling a medical class that “physicians are the attendants at the service station of life.” Of course, in Dr. Davenport’s days the gas stations were true service stations where someone pumped your gasoline, checked your oil and tires, washed your windows, and actually fixed problems with your automobile. Notwithstanding the dated image of the service station, it is an appealing metaphor. While the current phrase patient-centered care is bandied about as though it were a new idea, the consideration of “what the patient wants” has really never been far from the minds of good physicians. While we all have seen instances of domineering and inconsiderate medical care, the idea of a “patient-centric” approach is hardly revolutionary and new. It is unfortunate, albeit useful, that we need to proclaim that the health care we offer in our organizations is “patient-centric.” As health care has become more complex, specialized, and team-based it is easy to retreat onto islands of our professional turfs and focus on the solutions of isolated clinical problems. This professional convenience, however, turns patients and their inevitable co-morbidities of modern life into mere packages of DRGs in search of CPTs. The complex billing systems we dignify with the phrase modern electronic medical records are more than innocent co-conspirators in this crime. The success of the modern health care enterprise will depend on its ability to simultaneously fulfill the desires and needs of each patient in the contexts of their physical, emotional, and social problems. This will require teams and systems that are at once lean and adaptive.

 

7.    Long before science impacted the work of physicians, medicine was described as an art and I believe there still is much art to our work insofar as you might look at art as anything that is choice. Science and evidence cannot and will never define all of our choices in medicine. Two fundamental questions define modern health care. The first is: what does the patient (and family) really need and want? The second is: what does society want from its health care enterprise? The answers to the two questions are quite different. It is the first question that drives our essential transactions in health care, patient-by-patient and family-by-family. Of course these transactions must exist in the framework of society and the sense of what is right and reasonable to do for each individual patient. On the other hand as we create public policies and deploy health care systems, the second question comes heavily into play and begs the question: how much should a nation spend on the well-being of its people? So is 20% of GDP, for example, too much or is it not enough? It’s interesting to compare health care to food expenses. In some nations, families spend 60% of their household income on food, while in the USA food accounts for less than 10%. Granted that individual household expenses and national GDP are very different “apples and oranges” and the constraints of a nation differ from those of a household, it is clear that the more one expense dominates a budget the less remains for other necessary and desirable expenses. As a matter of public policy, however, ideally how much should a nation spend on its health care? How much on the education of its next generation? How much on its self-defense, on its research & development, on its infrastructure depreciation, or on its service of past debt? However you answer these questions, it is a fact that in the USA we are moving towards 20% of GDP for health care, and other advanced nations are not terribly far behind and moving towards us. That being said – a good third of the expense is generally recognized as waste – money spent that helps neither patients nor society.

Table from The Economist

[Table from The Economist]

Huffington Post

[Huffington Post July 10, 2014]

 

8.    An interesting point of view, written 2 years ago in the New England Journal of Medicine by MJ Barry and S Edgman-Levitan, called Shared Decision Making discussed a Picker Institute report that identified eight characteristics of care as the most important indicators of quality and safety from the perspective of patients. These characteristics are: respect for patient values, preferences & expressed needs, coordinated & integrated care, clear information & education of high value for the patient & family, physical comfort with alleviation of fear & anxiety, appropriate involvement of family & friends, continuity, and access to care. This list mirrors a more simple set of things that I believe patients want, since these are the simple things I want from my personal physicians: kindness, expertise, and convenience. Perhaps the attributes you might list would differ in number or terminology, but I think most people want roughly the same things. [MJ Barry and S Edgman-Levitan, Shared Decision Making. NEJM 366:780, 2012]

 

9.    Crayon drawing

I’ve shown this picture before in our Department of Urology “What’s New” column, but am compelled to share it again. The picture appeared on the cover of JAMA, a fact that dates this work since for the past year or so the new editor of the journal, Howard Bauchner, while he retained the art feature, moved it from its long-standing place on the cover of each issue. [JAMA 3017:2497, 2012. Toll E. The cost of technology. Copyright 2011 Thomas Murphy] Change is inexorable, however, and I have to say that he has done a superb job with the journal, both in format and in topic selection. The illustration shown (with previous permission of the author, Elizabeth Toll) shows a crayon drawing of a scene in a doctor’s office. The 7-year old artist drew her sister sitting on the examining table looking at the viewer in a most Vermeer-like fashion. Mother, with a younger child on her lap, is seated at the far right. The artist sits in between, at work on her picture, but also gazing intently at the viewer. The astonishing feature of the artwork however is the physician sitting at the far left, totally absorbed at the keyboard in the technology that is mandated in healthcare. The software has become a surrogate for the patient. The artist told it as it was and, no doubt the physician felt some shame on viewing the artwork. The enormous sums of money we have been forced to expend on clunky and dated software, compliance for poorly fashioned regulation, and the turmoil of the restructuring of a massive industry are a significant part of the waste. What will the next generation of health care look like when we leave behind the RVU, meaningful use, EPIC, and ICD-10? Such a world cannot be too far away. We hope academia, industry, and public policy can put together systems that are accessible, fair, lean, adaptive, and good for patients.

Halter, Bauchner, Malani Kerr

[Jeff Halter, Howard Bauchner, Preeti Malani, & Eve Kerr at a reception at   Preeti’s home 2013]

 

10.   The well patient exam has been challenged as “unnecessary.” So too has the routine pelvic exam, the PSA testing, and even routine urinalysis. This brings me to the question, what is the point of healthcare? As physicians we like to solve and fix problems of patients, but is that all that patients really want? Yes, often a patient comes with a very specific problem, but very often not all the problems are evident and sometimes they are deeply entangled with the other issues we like to call co-morbidities. This brings me back to Dr. Davenport’s thought. People and their cars have to stop at service stations from time to time. Sometimes they need gas or have a flat tire. At times the car isn’t working well and help is needed of one sort or another, but the problem isn’t immediately evident and the attendant must diagnose before repair. It is also useful, at other times, to have an expert look at the car, see how it runs, listen to the engine, and check under the hood. Preventive maintenance and inspections may discover occult issues for which early intervention can prevent serious harm. I can’t believe this isn’t true for human bodies and minds. People need to stop by the service stations of life from time to time just as well, for after all we are susceptible to far more ills than our motor vehicles. A doctor, or other health care provider, can look, listen, counsel, advise, and teach. The pastoral side of a doctor’s art should still be a major part of the toolkit. Not every problem discovered needs remedy, but every person should be seen, listened to, and examined periodically by some kind and expert attendant at the service stations of life where art and medicine converge. This is how we care for the human condition.

Gas Station

[1936 Union Gas Station. Main & Weatherlow. Lassen County History. Wikipedia – Historic gas stations]

 

 

 

 

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

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

 

 

Matula Thoughts July 4, 2014

Posted by

1

 

Ruminations on the Fourth of July, Michigan’s most important upcoming choice, brands, and mad men.

1. Happy Independence Day. The Fourth of July on a Friday this year offers a long weekend for most of us in the Michigan Urology Family, except for those on call or otherwise at work dealing with the inevitable urgencies and emergencies of urology that need attention. With a little luck, their Fourths will be easy and in 2015 they will get their chance to turn off their beepers (if we still have those archaic things). July 4 commemorates a moment in time when some mad men decided to break colonial bonds with England and form a more perfect nation centered on the rights of mankind to life, liberty, and the pursuit of happiness. No matter how you read the founding documents, it is difficult to believe that health care and education are not intrinsic and essential to those rights. We are mighty lucky to live in a place where a stable government and economy allow most people a fair shot at a safe and decent life, with opportunity for their children. By the luck of the draw we do not live in Syria, Iraq, Nigeria, or the many other places where safety and human rights are so massively lacking. The Trumbull painting of the Declaration of Independence depicts the five-man drafting committee presenting its work to Congress. It was a moment of great salesmanship, because many differing beliefs had to be accomodated. You can find the original painting in the Rotunda of the US Capital Building, where its message of accomodation is ignored routinely. A truncated version is found on the two dollar bill, although it cuts off 4 individuals on the left side and 2 on the right. Perversely, the engraver added 2 mysterious figures to the two dollar bill that are not present in the original Trumbull work.

Signing of Declaration

2 Dollar Bill

2. A two-dollar bill doesn’t buy as much as it once did and today people may need at least ten of them to handle a co-payment for their clinic visits. With a new fiscal year upon us, however, we need to collect and count those co-pays more carefully. Challenges are ahead in health care and not the least is the implementation of a mandated costly and cumbersome “electronic medical record” that caused us to discard our functional and familiar systems. We are getting used to new programs, but find they are changing our usual patterns of workflow, especially in the operating rooms where we already see deterioration of clinical productivity and morale as well without net gain to the patient or provider. Things will get better and we will cope and innovate our way through this, but whatever spin is given to the story this deterioration in productivity and workplace satisfaction is a fact and will remain so at least in the near future. This is a national story that I hear from colleagues around the country.

3. With changes of leadership at Michigan’s highest levels we anticipate a new sense of an educational vision, hopefully a rich and grand vision, for after all Michigan is a storied educational enterprise. The historic decentralized nature of Michigan’s academic and other units has been a key factor in its many legacies of success, whether in the LS&A School, the College of Engineering, the Musical Society, the Law School, the Athletic Department, the School of Art and Design, the Libraries, or the Medical School to name just a some of our Crown Jewels. The challenge of a university president is curiously binary. On one hand a great president must get out of the way and allow the units of the school to flourish, providing resources and support. On the other hand the president’s grand vision should inspire and bind the schools, colleges, and departments to allow them to develop and pursue their own grand visions, in some alignment with each other. Even better, a leader might synergize and energize the parts to make the university greater than the sum of its units in terms of the regional, national, and international conversations and experiments necessary to create a better “tomorrow.” While leaders often complain that they must make “difficult choices”, leadership is far more than the matters of cost management choices or personal beliefs. It has been said that President Harry Truman once wished for one-handed economists – that is advisors to give him single points of view rather than saying “On one hand this … while on the other hand that … .” Truman favored simple choices between clear positions. Modern life and modern universities, in particular, rarely allow for such simplicity. The world is ambiguous, changing, and full of risks. No single person can have all the answers and create the perfect strategies, but the wisdom of crowds is an emergent phenomenon that has been the central organizing feature of human civilization. The complexity of a great university, being naturally cosmopolitan, affords rich opportunity to extract the great wisdom intrinsic to the diversity of its “crowds.” Effective leaders find ways to use their human capital so as to make the best choices, figure out the best strategies, and run the most useful experiments that will leave our children a better tomorrow. This opportunity works well only in a free society. The ideal leaders for this scenario are not clones of Harry Truman or Steve Jobs, although we certainly need folks like them among other unique players in our crowds.

4. Michigan’s Medical School began in 1850 and was a simpler place back then consisting only of a Department of Medicine and Surgery. In 1869 a faculty house was converted into a dormitory for patients undergoing surgery, a rare event at the time, in the Medical School. Thus Michigan became the first university in the world to own and operate a hospital, although that first version was a primitive one. Soon thereafter a proper hospital was constructed and then another and another until 1986 when the present fifth University Hospital opened its doors. Now we have several additional hospitals and many other facilities. The administrative structure that encompasses the Medical School and Health System at Michigan for the past dozen plus years has been led by an executive vice president for medical affairs. We currently have a gifted leader, Michael Johns, in this position, although only for an interim period. He is a Michigan Otolaryngology alumnus, former dean of the medical school at Johns Hopkins, and recent chancellor of Emory University. The choice of the next EVPMA will be a big gamble for the University of Michigan, perhaps the biggest in its nearly two centuries. The success of our “medical affairs” – and all that they encompass – will drive the University toward the mean or toward the top percentiles in terms of reputation and financial stability.

UMMS Grad

[Carol Bradford, Mike Johns, & Jim Woolliscroft at UMMS Graduation 2013]

5. I’ve been involved with a number of searches and committees that targeted leaders at lower levels. Some processes have been crisp and successful, but university committees, as we know, can tie themselves up into knots. As one looks at the process of finding a successor to Dr. Johns for this important job it seems to me that two main questions should frame the selection. The first is simply: “As EVPMA what will be your fundamental driving daily concern?” The second question is: “Have you taken an academic health care enterprise from good to great and how can you assure the many tens of thousands of stakeholders at Michigan that you will be able to do this on our scale?” The main answers I would like to hear to the first part of each question are something like: a.) executing, maximizing, and perfecting the essential transactions of health care – one patient at a time and one system at a time, and b.) yes, with good evidence. The questions may appear simple superficially, but actually what are the essential transactions of healthcare? Most assuredly they are the essential transactions of clinic visits, making diagnoses, testing, operative procedures, hospitalization, medication, counseling, reassurance, and provision of supplies. They are also the transactions of deploying clinical teams, creating access to care, implementing new technology, as well as maintaining facilities that are safe, favorable, and state-of–art. The essential transactions of education (at the medical school level, the Ph.D. and postdoc levels, the GME level, and CME levels) not only are part of this spectrum of essential transactions, but they are the foundational purpose of our medical school and hospitals. The essential transactions of scholarship, research, and technology transfer speak for themselves, forming a core expectation by society from its universities and the global healthcare enterprise.

6. If we get this leadership choice and our clinical business right then everything else will follow – excellent education, excellent discovery, and solid financial performance. Our mission is described as tripartite: education, research, and clinical care. However, of the three parts clinical care stands apart. It is not merely the context for education and discovery, but also something more. Once responsibility is assumed for clinical care it becomes the moral trump card – subjugating either other part at any given moment. As it happens the clinical care piece, in today’s world, is also the economic engine on which the rest of the missions depend. Dr. Johns understands this story and the necessary intangibles of tomorrow’s healthcare leadership. We hope his successor will understand as well.

7. Academic medicine is always in the business of job searches, less often for presidents and EVPMAs, but more often for faculty, residents, nurses, administrators and staff. Many of these people are sought for specific leadership positions, but nearly everyone we hire will be or will become a leader of one sort or another. Tomorrow’s leaders need to be far different than those of yesterday. Most jobs have a primary expectation that is usually defined unambiguously in the title. Our next EVPMA is being sought to manage medical affairs, a complex and high-stakes expectation in FY 2015 USA. Such a job description does not and should not specifically seek a cardiac surgeon, urologist, health service scientist, anatomist, pathologist, RO1 funded researcher, health policy expert, nursing educator, medical school dean, or managed care CEO. While I believe the specific attributes for a major health care leader can be found in the two questions posed earlier, a number of essential personal characteristics (many are obvious, some are intangible) for any leader fall into three categories and apply with increasing importance up the ladder of higher levels of leadership. I have enjoyed batting these thoughts around and refining them with a number of colleagues and our leaders. A. Personal characteristics: kindness, moral center-character-integrity, sense of humor, stability, social flexibility, competence, and ability to listen > propensity to talk. B. Intellectual: curiosity, ability to deal with complexity & ambiguity, skill in finding clarity, high intelligence quotient, and higher emotional quotient. C. Organizational: shared beliefs and sense of mission with the organization, a “hands-on” capability coupled with proven record of successful delegation, consensus gainer, drive to understand stakeholders & value streams, decision-maker, team player, team-builder acquisitive of diversity, solid record of accomplishment, and will to lead.

8. Higher education in America historically focused on leadership. This happened first in 1636 with the founding of Harvard College, intended to produce the next generation of civic leaders, who at the time were mainly clergymen and public figures. A second generation of higher education began in 1824 when Rensselaer Polytechnic Institute, technically-focused as its name, was fashioned on European models of higher education to create a new generation of builders and entrepreneurs. A third generation was epitomized in 1891 at the University of Chicago where the higher degree of Ph.D. became the focal point for the full-fledged implementation of a research university. Sometime since then, a new model of higher education has evolved and Michigan is a prime example. This quaternary iteration (I can find no better descriptor) encompasses schools that indeed prepare sectarian and nonsectarian leaders, as well as engineers, architects, teachers, lawyers, healthcare workers, and other key participants of modern society. In addition these universities are still the powerful research engines that provide the new knowledge on which tomorrow will depend. However this fourth generation university also encompasses performing arts, athletic teams, technology transfer, patents, business ventures, health care enterprises, social policy development, global liaisons, and other pursuits intended for the well-being of mankind and the planet. Universities are the single entity in modern civilization that exists for the purpose of fashioning a better tomorrow.

9. Globe
The Quaternary University actually might not be such a bad term, it occurs to me. When you look up quaternary on Wikipedia you find it refers to the most recent of the time periods of the Cenozoic Era in the geologic time scale. This period began around 2.6 million years ago and is characterized by two big facts: one was (and is!) the series of glacial expansion and contraction and the other has been the proliferation of anatomically modern humans. The Quaternary Period is split into 2 parts called epochs – the Pleistocene and current Holocene, but many experts suggest that a third epoch, the Anthropocene, be considered as the era when humans began to profoundly change the global environment. If we are going to change the self-limiting path of the Anthropocene, quaternary universities may be our best (and last) hope.

10. However you may consider this time on our small blue dot of a planet (metaphor from Carl Sagan), our species has strongly marked its brand on it. The idea of branding hit full expression in healthcare recently. In the Midwest, the Mayo Clinic has been long-venerated brand since its early years under William Mayo (MD, Michigan class of 1883) and Charles Mayo (MD, Northwestern class of 1888). Henry Ford Clinic (1915) and Cleveland Clinic (1921) followed chronologically as similarly cherished brands in health care. In some ways the Michigan Block M brand in health care is a newer effort, in spite of the UM’s long history. This branding puts a label or sound bite on something that has long-existed. Patients have been seeking Michigan’s hospitals for care and physicians have been calling on UM physicians for help with their sickest patients since that first university hospital in 1869. Nowadays health care is far more complex than it was even 50 years ago requiring large coordinated teams, extensive facilities, expensive technologies, and complex systems. Health care is also far more competitive with billions of dollars in play even at single sites. Direct marketing of health plans and health care systems to prospective patients has caused even the smallest practices, hospitals, and health care systems to develop and advertise their brands. Everyone needs a brand to survive, so it seems. While commercial branding in health care is good news for television and newspaper advertising revenues, it does little to further the public good and diverts dollars from care, supplies, education, research, and development. However, it is a game that seems to be necessary today as even some of the most mediocre healthcare establishments taut their “international excellence” although marketplaces of public opinion eventually differentiate among products that are great, good, or poor. Even the slickest advertising campaigns ultimately fail if their objects of attention fall short.

11. The Economist Magazine last spring offered an article on Wally Olins, a man described as “a high priest of the religion of branding.” The intellectual footprint of Olins, who died 14 April 2014, is visible today all across the planet. To quote from the article: “The idea that not just bars of soap but organisations, people and places can have brands is such a commonplace one that it is easy to forget how recent it is. In the 1960s admen concentrated on devising brands and campaigns for specific products and markets, rather than creating an identity for the companies that made those products. The industry that churned out these campaigns was dominated by a handful of giant ad agencies, each divided between an officer corps of ‘suits’ (who managed the accounts) and an army of lower-status ‘creatives’ (who wrote the jingles).” [Schumpeter: The ascent of brand man. The Economist April 26, 2014. p. 66]

12. Interestingly, the Olins article was carried not in the obituary section of The Economist, but in the section called Schumpeter, named after Joseph Alois Schumpeter (8 February 1883 – 8 January 1950). This Austrian American economist and political scientist briefly served as Finance Minister of Austria in 1919 but was one of the most influential economists of the 20th century. He popularized the term “creative destruction” in economics and the weekly Economist section, under his posthumous byline explores themes that give evidence of that nature. While the idea of creative destruction is currently quite popular in healthcare, Schumpeter’s take on creative destruction was a rather dark view of evolutionary economics. He predicted that as capitalism leads to corporatism, the resulting social backlash would be antithetical to entrepreneurship and corporatism would become replaced by “laborism.” At least this is my take, as a non-expert in the dismal science.

Schumpeter   Man Men

Nevertheless, mad men matter and they seem to be mattering more in health care recently. The television series Mad Men began nearly 7 years ago, first airing on 19 July 2007, and its final “season” will end in 2015. While the show is entertainment its “fiction” hits close to the home of truth and reminds me of Daniel Pink’s important book “To Sell is Human.” (If you want a 30-minute version of this book you can find it, of course, on Amazon.) In a free society each of us is a salesman, and this is especially true in academic medical centers, where we sell our ideas, our expertise, our clinical services, our systems, and our trainees. As the current generation of Michigan’s faculty, residents, nurses, PAs, researchers, staff, and administrators we safeguard the integrity and the quality of our products that bear the Michigan imprimatur of “leaders and best.” We carry the honor of this responsibility one patient at a time, one resident at a time, one scientific presentation at a time, one clinic at a time, one site at a time, and one ACO at a time. Every time we fall short in any of our essential transactions of healthcare (and one way or another, at one time or another this will happen to each of us) we place our brand at risk. Perhaps, however, part of the Michigan difference is the individual and corporate learning that we derive from experience to improve ourselves, our products, and ultimately our brand. The stakes for us and the Michigan brand have never been higher and our future is more heavily contingent on the choice of the next EVPMA than for that or any other position at any time in Michigan’s past.

Best wishes, Happy Fourth of July, and thanks for spending time on “Matula Thoughts.”

David A. Bloom, M.D.

Matula Thoughts June 6, 2014

Posted by

1

Matula Thoughts Logo1
Challenges of FY 14, leadership, conflicts, & our successors.

1. Not so long ago fiscal year 2014 loomed large as an ominous transition point in health care with the collision of multiple forces of major impact. The rising rate of spending relative to GDP, the struggling world economy, climate change, expensive new pharmaco-technology, increasing economic and healthcare disparities, aging populations, the growing complexity of the health care work force, unintended consequences of large scale legislative health care legislation, underfunded necessities of research and education, duty hour dysregulation, are only some of the many forces that quickly come to mind. Other factors are less immediately obvious, but no less significant. New appreciation of the complexities of chronic disease management has rendered our models of health care delivery archiac (e.g. the primary care-specialty care model, employer based coverage, and even the very idea of “an insurance model” to manage health care for a large population). The effects of gerrymandering in determining election outcome, and hence legislation and public policy, similarly have impaired the public good. All of these things have come together now, more than ever before, to destabilize the economy and structure of healthcare in the United States.

2. Nevertheless, this feared watershed fiscal year is in it’s final month and, for the most part, the essential transactions of health care delivery – clinic visits, medication prescription, diagnostic testing, operative procedures, provision of supplies, education, research, and innovation are still happening on a daily basis even though this work seems to be done against the grain with increasing difficulty. We will soon have our FY 14 numbers (patient visits, operative procedures, RVUs, grant dollars, satisfaction scores, papers written, patents claimed, operational margins, days of cash on hand, etc.) and analysis of these will show us where we stand. However it comes out, even if our fiscal head is above water which we expect, we will be standing well below our potential as a department, as a medical school, as a health system, as a university, as a state, and as a nation. Irrespective of the constraints of the larger environment (including our self-inflicted wounds of the HITECH Act, legislative gridlock, and reactive regulation such as the duty hours story) we have the ability and duty to our patients, trainees, employees, community, and our children to do our work better. While the FY 14 boogeyman didn’t bring the world to a screeching halt, we still need to rapidly find new ways to maintain the missions of academic medicine – clinical care, education, and research. Underpinning all this is our essential deliverable: kind and excellent patient-centered care, thoroughly integrated with education and innovation at all levels. If we get this right, one patient at a time as well as one system at a time, then most everything else we want will follow.

3. Today’s date, June 6, is a big anniversary for a far more monumental watershed point in time for mankind. Operation Overlord was launched on this day in 1944. Had this massive organizational feat failed the world would be very different today. In fact it’s leader, Dwight David Eisenhower, was not so sure of success given the myriad contingencies in play beginning at the launch of Overlord exactly 70 years ago and he accordingly prepared an alternative brief statement on July 5 to be released in case of failure: “Our landings in the Cherbourg-Havre area have failed to gain a satisfactory foothold and I have withdrawn the troops. My decision to attack at this time and place was based on the best information available. The troops, the air and the Navy did all that Bravery and devotion to duty could do. If any blame or fault attaches to the attempt it is mine alone.” Eisenhower offered no optics, spin, or scapegoats.
Eisenhower
[The Eisenhower mea culpa never needed to be sent.]

4. Eisenhower was not unchallenged as a leader or soldier even though he had the trust of Roosevelt and Churchill. His British counterparts were demeaning: Bernard Montgomery said “Nice chap, no soldier” and Alan Brooke proclaimed that Eisenhower knew nothing about strategy and was “quite unsuited” to be Supreme Commander. In retrospect, those comments seem to reflect mere petty jealousies as the outcomes of Eisenhower’s leadership at that key point in time dwarf any accomplishments of those detractors. Leadership matters greatly. While leaders have great latitude in times of relative peace and stability, they have consequential impact when times get tough. The world today would most likely be very different had it not been for Eisenhower, Roosevelt, and Churchill seventy years ago, and the same holds true as such for Lincoln and Washington in their times as well. Much more recently and locally look at Bill Ford and Alan Mulally for extraordinary leadership success. On the other end of the spectrum leaders of very different character such as Pol Pot and Adolph Hitler hijacked their constituencies and neighbors into terribly dark days. This is evidence of the problematic duality of our species. We are the only one of the rare eusocial species who can deliberately select leaders and determine our governance – but that is another story, better told by E.O. Wilson. [Two books of reference: a.) Anthony Beevor. D-Day. The Battle for Normandy. b.) Edward O. Wilson. The Social Conquest of Earth.] [Pictures – Normandy beach 70 years ago and same beach and American Cemetery on my visit in 2010]
battlefield
screenery
Screen Shot 2014-06-05 at 3.10.40 PM

5. Leadership was at play last month at the AUA national meeting in Orlando, on many podiums and in many committee sessions. One noteworthy example was the Michigan Urological Surgery Quality Collaborative (MUSIC) conceived by Jim Montie and “Eisenhowered” by David Miller. At the MUSIC session I saw urological colleagues participating from around the state including a number of our own former students and residents. Dr. Miller and Dr. Brian Stork gave excellent presentations, highlighting the beautiful social/scientific collaboration of urologists who have, through trust and hard work, pooled their individual and local experiences to figure out to deliver better care at better value in collaboration with Blue Cross/Blue Shield. This should be a model for the future in health care. Especially inspiring was to see how MUSIC has brought private practitioners to podium presentations and to authorship positions thus erasing the “barrier” between the academic and non-academic sides of urology. Leadership has also been in play with Stuart Wolf’s amazing work overseeing the AUA guidelines. Prominently visible was the running video on guidelines showing Michigan faces throughout the AUA including Stuart, Quentin Clemens, and Ann Gormley. John Park’s Mott video was also running outside the pediatric sessions, showing Julian Wan, Vesna Ivancic, and Kate Kraft as well as John Park and Carla Garwood, representing our pediatric nursing team. A video also showed members of the prostate SPORE group. The Reed Nesbit Society held its reception on Sunday night. This has become a lovely annual habit and is financed by both the Department of Urology and the Nesbit Society. This year we hosted around 120 people. Friends of the department, new and old alumni, faculty, and residents acquaint or re-acquaint themselves. If you missed it this year consider joining us in 2015 in New Orleans on Sunday, May 17. Perhaps the biggest news of the meeting was the awarding of the AUA Gold Cystoscope to our Associate Professor Will Roberts later in the convention. Ed McGuire received this honor back in 1982, so out of a total of 38 Gold Cystoscopes, Michigan Urology now accounts for two. David Miller was awarded the Society of Urologic Oncology (SUO) Young Investigator Award. Ted Skolarus, Jeff Montgomery, Florian Schroeck, and Khurshid Ghani were awarded Best Abstract at the 2014 VA Forum. Bahaa Malaeb, Aruna Sarma, and Rod Dunn received Best Poster Award for their work on the relationship between diabetes and sexual dysfunction.
Roberts
[Photo by Wendy Roberts]

6. National meetings of specialties are the fundamental marketplaces for the ideas, products, and talents of healthcare processions. Large organizations such the AUA, ACS, ASCO, AAP, EAU, or SUO may seem like an alphabet soup to outsiders, but they are the interfaces between today and tomorrow for medical specialties. Each year in between the meetings faculty, residents, and research teams develop ideas, create hypotheses, test products, and perform other acts of scholarship even while doing the never-ending daily work of clinical care and education of our successors. The chance to stand at a podium and present one’s observations to the world of urology at large is a big moment for residents, and aggregation of those moments develops reputations and careers for faculty. Michigan Urology had a big year at Orlando’s AUA meeting. We used to try to count the number of appearances for our faculty, residents, and students at this meeting and found the count running well beyond 100, but this year I won’t even try that little exercise of hubris. The bottom line is that Michigan Urology’s people and ideas are a major force in this marketplace of urology. I had too much fun talking and taking pictures at our Nesbit reception so I deferred my brief “State of the Department” presentation for an appendix in this “What’s New.”

7. The AUA national meeting is heavily subsidized by urologists as well as the corporate world. We and our departments spend big dollars on the research that produces the talks. We also pay travel expenses for the faculty, residents, and nurses who give the talks and listen to others. The practice of urology is a profession that exists within the social industry of healthcare. We depend upon social opportunities such as this annual meeting to exchange and stimulate new ideas, to see new products, to network for new opportunities, to find jobs for our trainees, and to develop collaborations. While replete with opportunities, the interfaces of the medical profession, industry, and academia have ethical risks. We are all human, and some of us test boundaries of self-serving behavior more than most others. A smaller number, reflecting the dark side of our duality, wander into territories of mischief or even deliberate wrongdoing thus rules are necessary. We recoiled when we read about the Ivy League professor promoting his (unacknowledged) proprietary antihypertensive drug to a class of medical students as THE drug of choice, or learn of an orthopedic surgeon routinely using his own invention in patients without full disclosure of his commercial interest. Our own institution is not blameless as seen recently by the professor in another department who gave confidential drug trial results to hedge fund operators that allowed insider trading. These people are scoundrels and dirty our profession. Not all conflicts are purely monetary and some are conflicts of commitment. It is not uncommon for many of us to try to wear too many hats, even though our heads are only finite in dimension. In fact we each actually do need a few hats, for rain, cold, construction work, mosquito protection, etc. Ego, however, makes us overestimate our head size tempting us to accept a few too many. You could call this phenomenon the hat trick of ego or perhaps “the blinding effect of arrogance”, a risk for each of us.

8. Academia and industry need to intersect for the public good. We sometimes manage this intersection well and other times not so well. One good example is histotripsy, a technology invented here at Michigan by a team including our own Will Roberts, along with radiology and biomedical engineering colleagues. As a department, Michigan Urology has invested a decade of time and money in Will and this idea. Ultimate product development, however, exceeded our capacity and required initial venture capital to the tune of $11 million. Within only about four years now clinical trials for BPH are underway (with full disclosure) at a number of sites – Tim Schuster in Toledo (Nesbit 2004) did the first histotripsy prostate enucleations. We have a thorough conflict management plan that details the extent of our departmental involvement in this product development and its trials. We are doing this well and properly. It is important to develop good standards to manage conflicts of interest and conflicts of commitment, although ultimately we must depend on shared values and appropriate behaviors. [Actually, and somewhat unfairly, the University of Michigan through its policies rather than our Department of Urology, will assume most of any financial gain if HistoSonics Corporation is successful.]

9. Although I was present at the discussions and votes around our medical school’s new conflict of interest policy, I was uneasy supporting the stipulation that faculty, residents, and nurses must refuse hosted social occasions at national meetings. As we prepared to go to the AUA meeting messages went out that our new conflict of interest policy warned against accepting food or drinks from the pharmaceutical and industrial representatives who otherwise would be with us in Orlando supporting the meeting. In the past I have freely enjoyed the hospitality of, for example, the Olympus Corporation with our representative Bill Herpek while on other occasions I’ve picked up the check for the burgers he and I had at the concession stands in the exhibit halls. Bill has become a friend and colleague for 25 years, quickly available for replacement scopes in the OR when urgent repairs are necessary, or finding us good deals (in the world of competitive bidding) when we need new technology. The extent of our mutual hosting has really been nickel and dime, not paid excursions, serious gifts, or stock options. (In full disclosure he did give me a wildlife calendar once.) Might someone assume that our friendship or the burger I bought him translated into a sweeter deal for the cystoscopes we purchased? Doubtful – but our relationship does provide a basis for fair deals and open communication. It’s not just our own Michigan policies that don’t seem quite right. When we had Marston Linehan here recently for a Von Hippel Lindau symposium, NIH policy required him to pay for his own dinner at the event. Given the shenanigans of Congressional and other leaders, I am embarrassed by the double standards. Our colleague here at the University of Michigan Charles Eisendrath tells us that in his journalism career the self-imposed standard was that “if you can’t eat it or drink it, you shouldn’t take it.” On the other hand the egregious exploits related to insider trading I mentioned earlier involved far more than cheeseburgers, but I’d contend they didn’t begin on the ”slippery slope of a lunch” at a national meeting, but rather involved cozy self-serving deceit right from the start. How about participation on heavyweight national boards by university leaders? I have heard the many “pros” of the argument, but really our top academic and health system jobs are not only quite well compensated but they also seem to be demanding enough on a 24/7 basis. Yes the interface between academia and industry needs to be somewhat fluid, and yes leaders “can learn things” and develop relationships on major boards. On the other hand, proper board service is demanding of time and commitment, things that might be more reasonably offered when individuals are no longer in the pilot’s seat for a major enterprise. The hat trick of expertise is an alluring illusion and we are each susceptible to its temptations. No policies or laws can substitute for a good internal compass, although any compass can be swayed by strong elemental forces (iron, silver, or gold). An essential part of our jobs as teachers and role models in the health care industry is the duty of imparting a strong moral compass to our successors. As I look at our Nesbit alumni – it seems that Michigan Urology has done this well for nearly 100 years.

10. Our foundational mission at the University of Michigan Medical School and Department of Urology is to train our successors, and the evidence of our success is beautifully visible each year at the Nesbit AUA Reception. As you know, the context for education of our successors is necessarily the practice of medicine amidst the innovation of the science, technology, and systems of healthcare. Our essential deliverable of all this is kind and excellent patient-centered care, thoroughly integrated with innovation and education at all levels. The basic building blocks of education are medical school and residency training. Michigan’s medical school graduation took place just a few weeks ago and our 169 graduates will go out to start their residencies in the next few weeks. Michigan students are highly prized in training programs around the country, reflecting the excellence of our medical school and the departments in which students discover their careers. The match rate this year was 100%, meaning that all Michigan students were accepted by the training programs they sought. Of these 28% will stay at Michigan for training and 32% will remain in our state. The others will go to top programs around the country.

Five Michigan medical students went into Urology this year: Denise Asafu-Adjei to Columbia University Physicians & Surgeons in New York, NY; Spencer Hiller to Beaumont Health System in Royal Oak, MI; Zachary Koloff to University of Michigan in Ann Arbor, MI; Kola Olugbade to SUNY Downstate Medical School in Brooklyn, NY; and Brian Orr to Indiana University Medical Center in Indianapolis, IN.

Of our four new urology interns coming to our program: Ella Doerge from Baylor College of Medicine in Houston, TX; Zachary Koloff from University of Michigan Medical School in Ann Arbor, MI; Ted Lee from New York University School of Medicine in New York, NY; and Parth Shah from University of Texas Medical School at Houston, TX. Michigan residencies pick the strongest students from other schools as well as ours – of the interns that entered in 2013 for all specialties here 41% were members of AOA, the medical school honorary society.

We have three new fellows: Sapan Ambani from University of Michigan for a two-year endourology fellowship, Lindsey Herrel from Emory University for a three-year urologic oncology fellowship, and Yahir Santiago-Lastra from Massachusetts General Hospital in Boston as a clinical program trainee in the female medicine and reconstructive surgery (urology) for two-years.

Graduating Chief Residents: Sapan Ambani will be staying with us for an endourology fellowship. Dan Miller will be doing a fellowship in endourology and minimally invasive surgery at the University of California San Diego/Kaiser Permanente. Jackie Milose is going to Northwestern in Chicago for a GURS Fellowship. Matt Smith is headed to Muskegon to work with the team of urologists at West Shore Urology. Fellows: Nina Casanova is completing her pediatric urology fellowship. Florian Schroeck is joining the faculty as an Assistant Professor in the Department of Urology at Geisel School of Medicine at Dartmouth. Anne Suskind is headed to UCSF on the faculty as an Assistant Professor in the Department of Urology.

The highest step in the academic ladder is the rank of Professor and this title was granted by the University to Quentin Clemens, Khaled Hafez, Brent Hollenbeck, and John Park. Jeff Montgomery became an Associate Professor. Academic promotions are recommended and approved by each departmental promotion and appointment committee, then by one of the three Dean’s Advisory Committees (the faculty vote on memberships for these), then by the Medical School Executive Committee (also elected by faculty vote), then by the Provost, and finally by the Regents. These promotions are effective September 1.

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

David A. Bloom, M.D.

Matula Thoughts May 2, 2014

Posted by

0

Matula Thoughts May 2, 2014

Endurance

 

  1. May is here at last, a month encompassing the anticipation of summers, vacations, family time, and recreation unfettered by heavy clothing. We have endured another winter in Ann Arbor, this one more challenging than average. Yet our seasonal challenges are nothing compared to those in other parts of the world where climate, geology, society, local economy, and government are less stable. With Independence Day two months away we have to be thankful for the serendipity of our national circumstances. Serendipity is a word defined by two components – luck and sagacity. The United States of America has had the good luck of great resources and sagacious founders with unusual wisdom, although that luck and wisdom were not shared with the indigenous Native Americans and generations of imported slaves.
  1. Democratic government, hardly perfect as we exercise it, is a work in progress. Yet for all its flaws it appeals to people around the world who want fair and rules-based government that allow people to speak their minds, have a fair shot at playing out their lives, and creating good futures for their children. Democracies tend to be richer than non-democracies, less corrupt, and less likely to resort to war. Yet for all of its appeal, democracy is under threat through a.) imperfections in its various deployments, b.) failure to “stick” where they have recently been initiated such as after the Arab Spring, or c.) competition from other belief systems of government. The alternatives of oligarchy, military dictatorship, kleptocracy, communism, sectarian rule, despotism, or royal ascendency are hardly preferable to most people. The aspirations we have for government at national scales hold true at the local levels and indeed within nearly all organizations including the University of Michigan and the American Urological Association – two organizations of immediate interest. Academia is no different from other organizations, in spite of its long history and self-ordained privileges. How we govern ourselves at any level matters deeply to the individuals involved and their ability to reach their potentials of performance and happiness.
  1. What about the May seconds of the past? Of the many events to consider the following caught my attention. In 1536 Anne Boleyn, Queen of England, was arrested and imprisoned on charges of adultery, incest, treason, and witchcraft. While we have to thank her husband, King Henry VIII for giving the Company of Barber Surgeons the Royal Charter just 4 years later, things didn’t go so well for Anne. Henry’s successor in England, King Charles II on 2 May 1670 somehow felt he had the right and authority to give a permanent charter for the Hudson’s Bay Company to open up fur trade in North America without consideration of the indigenous economies. Friendly fire wounded Stonewall Jackson in 1863 while reconnoitering at the Battle of Chancellorsville on the second of May and he died 8 days later. In 1885 the Congo Free State was established by King Léopold II of Belgium, presaging untold more human misery. On 2 May 1933 Hitler banned trade unions (Gleichschaltung) and on that date in 1945 the US 82nd Airborne Division liberated the Wöbbelin concentration camp finding 1000 dead prisoners, most of whom starved to death – sad bookends to the Third Reich. In 2011 May second was the last day for Osama bin Laden.
  2. Mayday           Engraving May Days have been traditional times of celebration. Many are cheerful festivals of spring. Some are more somber rememberences. May Day in Chicago celebrates the labor movement and is known as International Workers’ Day, in commemoration of the Haymarket massacre of 1886. This occurred (actually on Tuesday May 4) at a labor demonstration when workers went on strike for an eight-hour workday and someone threw a dynamite bomb at police as they tried to disperse the crowd. Seven police officers and 4 civilians were killed, many others were injured. Eight anarchists were accused of the crime and of these 7 were sentenced to death and one to a term of 15 years in prison. Of the death sentences, 4 were hanged, one committed suicide in prison, and the other 2 were commuted by the governor to life in prison. So in terms of life, it wasn’t quite an eye for an eye. May Days show humans at our best and worst. [Pictures from Wikipedia. On left: Mayday festivities National Park Seminary, Maryland 1907. On right: Engraving from Harper’s Weekly]
  1. Neighbours                Hn8 A friend recently told me about a provocative short film (8 minutes) by Norman McLaren (1914-1987) that encapsulates the bright and dark duality of the human condition. Born in Scotland McLaren developed a career in Canada as an animator and film director. His 1952 film Neighbours won an Oscar (in 1953) for best documentary. You can find this and watch it via Wikipedia or buy it via iTunes. My appreciation to Harry Cross, fellow Ann Arborite, for turning me on to McLaren, whose other work – particularly the short film Pas de Deux – is equally worth watching. By the way, if you use Wikipedia like I do, you should consider a voluntary donation to help support it. It is an amazing and living library, and although imperfect, it gives you the tools to improve it. One of our newer faculty members, Khurshid Ghani noticed it didn’t contain an entry for Reed Nesbit, our great professor in urology here at Michigan. Khurshid figured out how to get an entry into Wikipedia and got it done. Speaking of Nesbit we will be having our annual AUA Nesbit Society Reception on Sunday, May 18 from 5:30-7:30 PM at the Hilton Orlando in the Sun Garden. We look forward to seeing many of you there and if you haven’t RSVP’d please do so to Sandy Heskett by email at sheskett@umich.edu. [Photo on left – McLaren’s Neighbours. On right – Dow Chemical’s logo for our species]
  1. A while back two articles in The Lancet caught my attention. The first was the single-page piece by the editor, Richard Horton called “Offline: Social chaos – the ignored tragedy in global health.” [The Lancet 283:111, 2014]  The second was a two-page article by Arthur Kleinman in The Art of Medicine Section called “How we endure.” [The Lancet 283:119, 2014] The first article talked about the fierce debates regarding universal health coverage, Millennium Development Goals, non-communicable diseases, and social determinants of health. Yet, Kleinman observed: “…almost the entire field that is global health today has built an echo chamber for debate that is hermetically sealed from the political reality that faces billions of people worldwide. That reality is social chaos: the disruption, disorder, disorganization, and decay of civil society and its institutions. Social chaos erodes societies, destroys communities, eviscerates health systems, and eliminates any remaining vestiges of hope individuals might have for better lives. And yet social chaos is nowhere on the global health agenda. It is systematically ignored, marginalized, or censored.”
  1. Arthur Kleinman was chair of the Department of Social Medicine at Harvard Medical School and is an MD with an MA in Social Anthropology. A medical anthropologist, he brings personal as well as professional insight to his discussion of “How we endure.” The essential concepts in his essay are missing from standard medical education curricula, indeed they are left out of most formal educations society offers today. Kleinman’s broad view identifies a core element of the human condition, namely suffering. He writes: “ … for billions of poor people in our world, enduring pain, misery, and suffering is not only a description of their everyday reality but the moral message that they share with their children. And this is true as well of many people in rich societies who must endure seriously debilitating illnesses, disabling accidents, terminal organ failure, end-stage neurodegenerative conditions, and the final days of dying.”
  1. Kleinman illustrates his article with a single photograph that you will recognize immediately. It is Dorothea Lange’s image in the Migrant Mother series, showing Florence Thompson with two of her children in 1936. Kleinman’s concluding paragraph begins: “Assisting family and professional caregivers as well as patients to endure may not be assessed today as a measure of the cost-effectiveness of health-care systems, and yet it is at the very core of what human experience is about and what caregiving should be about. Our cultural images today seem blinded to life’s limits and dangers. While emphasizing human flourishing and celebrating happy outcomes, they obscure the reality of human conditions. Physicians can work hard at achieving the best outcomes, while still acknowledging that their patients, like themselves, must prepare for lives lived under some degree of constraint. This means that each of us at some point must learn how to endure: the act of going on and giving what we have.”
  1. As physicians, especially in our younger years, we buffer ourselves with the binary illusion that disease and disability, may be sitting on the examination cot or operating room table while we stand in our healthy professional space spared from such misfortune. Of course this is a convenient self-delusion. The extent of our ability to imagine that the healer/patient duality is ultimately a singularity is related to our ultimate success as physicians. The additional buffer of our specialization as urologists adds to the delusion. We, no less than our patients, must endure many challenges and burdens though our lives, and our personal and professional successes can be synergistic. If these thoughts intrigue you, read The Lancet paper, or even go a little deeper in the internet to hear and watch Kleinman’s William James Lecture from December 5, 2011 called “The Unfulfilled, Yet Not Unfulfillable, Quest for Moral Wisdom in Academic Life: Why William James Still Matters.” It is an interesting title, “the quest for moral wisdom in academic life.” Then check out Wikipedia on William James who, by the way, was educated as a physician although he never practiced medicine. (Harvard Medical School 1869).

 

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

David A. Bloom

 

 

Matula Thoughts April 4, 2014

Posted by

0

Matula Thoughts April 4, 2014

Michigan Urology Family

Matula Thoughts Logo1

Disparate thoughts on bugs, flags, and April 4

  1. It has been a full year since we began to post our Michigan Urology Department monthly global email called “What’s New” on this blog, labeled “Matula Thoughts,” as explained in our first posting. The blog format allows the postings to be kept chronologically (so I can try to prevent repetition) and it doesn’t clutter up email. While much more relevant detail about our department, faculty, and personnel is found in our weekly internal “What’s New,” Matula Thoughts, on the first Friday of each month, ranges further afield with around a dozen items related to our department, history in general, or issues of the day. Mainly, I write this because I like to collect and connect ideas, events, and thoughts even if many seem unrelated directly to our specialty. If you read this, I thank you for your interest and invite your comments.
  2. We take for granted today’s world of scientific specialty-based medicine, but it’s worthwhile to occasionally reflect on the past. Genitourinary surgeons, as urologists previously described themselves, found a big part of their daily work related to communicable diseases, particularly venereal diseases. Today, other specialties have picked up a large part of this burden and urologists have moved off of the front lines of communicable disease for the most part.  While C. difficile has refocused our attention recently, hand washing routines, antisepsis, asepsis, antibiotics, and immunization underpin our work every day.
  3.  This arduous winter may have occasionally flagged our spirits, but spring is in the air with many of its harbingers.  Flu season should be winding down. In the US the season usually begins in October, peaks in January-February,  and ends around May. Infectious diseases still account for significant human misery and mortality, but vaccination and antibiotics have hugely reduced the toll. Vaccination has been pretty well shown to be effective in mitigating disease for the past 2 centuries although influenza challenges us with novel presentations of the viruses each season. Still, it amazes me that our employee vaccination rate at the UM health system is only  86%. Conspiracy theories, myths, and individual fears (and a few rare true allergies) seem to account for the gap from 100%. More amazing to me is the infrequent deployment of handkerchiefs for sneezing and coughing.  If I ever get arrested for assault it will likely be on an airplane when the person next to me sneezes in the open one too many times.  Handwashing is a good thing after a sneeze, cough, or even for random reasons.  Amazingly, in our new Mott it is hard to find free sinks for this use.  Influenza is transmitted by viruses, and the alcohol-based hand lotions are useless against them (also useless for Clostridial spores, as well as most garden variety bacteria).  Anyway, my advice in this concluding flu season, for next season, and in between – buy some handkerchiefs, carry some kleenex, and wash your hands compulsively. The simplest solutions are usually quite effective.
  4. ICS_Lima.svgFor centuries we have known that many diseases are contagious. Flags were routinely flown from ships to warn a town that disease was on board. The idea of quarantine comes from 17th century Venetian term quaranta, indicating the 40-day waiting period on ship to be certain that no active communicable disease was present before disembarking.  Yellow flags have a long history of marking locations of disease, although green, black, or even a skull’s head have been used. The Lima (L) flag, or yellow jack is still in use, although yellow jack was also a name for yellow fever. A plain yellow flag (Quebec or Q) may have also been so used in the past, but as meanings change with the times, today a plain yellow Q flag means a ship is free of disease and can be routinely boarded and freely disembarked. We are somewhat insulated from the stark terror that infectious diseases inflicted on populations, not so long ago. A gathering storm of Ebola virus or renewed treachery from influenza may resurrect the ancient panics of lethal infectious diseases.  Our colleague Howard Markel in the department of Pediatrics, wrote an excellent book called Quarantine! in 1997, that is well worth a place on your shelf.
  5. Immunization has had a profound effect on history. Edward Jenner is assigned priority in the story of vaccination, although others even centuries earlier  understood its potential intuitively and utilized inoculation principles empirically. But Jenner was methodical, communicated his ideas well, and gets the credit for smallpox vaccination in 1796.  Smallpox was a terrible disease, apparently wiping out much of the indigenous American population after European explorers brought the virus over across the Atlantic. Well after Jenner,  the disease persisted and it has been estimated that in the 20th century alone smallpox killed 500 million people. The last natural case of smallpox was diagnosed in 1979, and it is believed now to be totally eradicated.
  6. 800px-US_20_Star_GreatStar_Flag.svg  800px-US_flag_20_stars.svgSpeaking of flags, Congress on this date, 4 April 1818, adopted a national flag standard with 13 alternating red and white stripes (for each of the original colonies) and a star for each of the 20 states at the time. This was the suggestion of U.S. Naval Captain Reid with a new star to be added for each new state. Up to then then no official standard existed and the number of stripes had grown to 15 with no particular arrangement of the stars specified.  A number of variants  were then in use including the circular arrangement of stars of the so-called Betsy Ross flag. The blue square, by the way, is called “the canton” in flag-speak and even Reid’s model allowed variable arrangements in the canton.
  7. At that point in time the University of Michigan was only one year old and its next 21 years of operation in Detroit would be significantly interrupted by cholera epidemics until the move to Ann Arbor. No medical school existed at the university in those years (although one had been envisioned from the start) and urology as a field was represented mainly by uroscopy and lithotomy in the hands of self-styled experts.
  8. Some questions of priority, such as the chicken and egg, will likely be matters of debate for time eternal, whereas others are deciphered through historical study or modern scientific method. As an alumnus of Walter Reed Army Medical Center, the yellow fever story has been a matter of interest to me, not just for its influence on public health, but also for its priority in establishing insects as disease vectors. So as I was recently investigating a series of early American medical student theses concerning genitourinary conditions I was surprised to find that priority challenged. Yellow fever was the first illness shown to be transmissible via filtered human serum and transmitted by mosquitoes, and it was Reed who led this effort to contain it around 1900. The disease is caused by the yellow fever RNA virus of the family Flaviviridae.
  9. The story I knew went back to Carlos Finlay, a Cuban physician (graduate of Jefferson Medical College 1853), who “first” proposed in 1881 that yellow fever might be transmitted by mosquitoes rather than direct human contact.  Yellow fever was a big problem in early American history. A Philadelphia epidemic in 1793, then capital of the United States, killed nearly ten percent of the population causing the national government including President Washington to flee the city. Subsequent epidemics devastated Baltimore, New York, Charleston, Shreveport, and Memphis to name some hard-hit locations. Since the losses from yellow fever in the Spanish-American War in the 1890s were extremely high, Army doctors began research experiments with a team led by Walter Reed. Their work proved Finlay’s ″Mosquito Hypothesis″. Yellow fever was thus the first virus proven transmitted by mosquitoes. Reed fully credited Finlay with the idea for the yellow fever vector. William Gorgas MD applied these principles, eradicated yellow fever from Havana, and then combated yellow fever during the Panama Canal construction, after the previous French effort failed largely due to yellow fever and malaria.
  10. So it was a big surprise to me to come across a now obscure paper from 1848 by Josiah Clark Nott entitled: Yellow Fever contrasted with Bilious Fever – Reasons for believing it a disease sui generis – Its mode of Propagation – Remote Cause – Probable insect or animalcular origin, etc. [New Orleans Med Surg J 4:563-601, 1848] Not quick himself to claim priority, Nott wrote “There is no novelty in the doctrine of Insect or Animalcular origin of diseases. Many of the older writers, amongst who are conspicuous Linnaeus, Kircher, and Nyander, have promulgated such an opinion, and …”  Nott, a paragraph later said this: “As far as doctrines are concerned in the history of Medicine is little more than a recital of successive delusions, and we have too much reason to know, that it takes almost as much time to uproot a false medical doctrine as a false religion, when it has once seized upon the public mind.” He then discusses the false doctrine of miasma, or bad air, as the putative cause of malaria since the days of Hippocrates. A few years after writing this paper, Nott lost 4 of his own children to yellow fever within a six day period. As I was tracing the curious career of Nott, I was amazed to find the coincidence of the fact that as a general practitioner in 1854 he delivered an infant boy who would be named William Gorgas.
  11. Today, April 4,  also marks the date in 1968 when Martin Luther King, Jr. was shot and killed in Memphis. Of relevance to this is a recent book review that is among the best reviews I’ve ever read and it is called “The scholar who shaped history” by Drew Gilpin Faust [The New York Review of Books, March 20, 2014]. The book featured is the third in a series produced by Professor David Brion Davis of Yale University, a man quite fortunate  in that luck and excellent public health gave him the opportunity at age 88 to complete his great trilogy. This third book in the set is called The Problem of Slavery in the Age of Emancipation, and while you probably won’t read the entire 422 pages of it, let alone Davis’ previous two books, you should read the 2 pages or so of Professor Faust, herself an astonishing intellect.
  12. For those friends of Michigan Urology who will be in Florida for the American Urological Association annual meeting in May, please stop by our Michigan Nesbit Society Reception where you will see our flag, in one or more of its iterations, on display that Sunday evening on the 18th at the Hilton Orlando Sun Garden. RSVPs are helpful so please let Sandy Heskett know at sheskett@umich.edu.

    LogoB
    Best wishes, and thanks for spending time on “Matula Thoughts, David Bloom

Matula Thoughts February 7, 2014

Posted by

0

Matula Thoughts Logo1
Matula Thoughts February 7, 2014

Michigan Urology Family 

Curiosity, novelty, and the elements of change: Norse mythology, ICD-10, PACs, and other thoughts.

  1. granddaugter and Molly Today, February 7th is the 38th day of 2014 and given our recent experience with the arctic temperature blasts and deeper snow than we’ve seen in Ann Arbor in many years, who cannot yearn for those lovely Michigan summers? (Picture from “Up North” in summer with 4-legged Molly seeking a dietary novelty, held barely out of range by Charlotte) By the way, in case you are curious, 2014 is NOT a leap year, so we have only 21 more days of February and 327 days in this calendar year to extend our curiosity and good work in the Department of Urology at the University of Michigan. So you might ask, is the glass partly empty or mostly full? While a matter of one’s perspective, the latter viewpoint is the more productive option, as it conditions us to seek comfort and novelty in that glass of opportunity. All of us crave novelty just as do Charlotte and Molly. Novelty rewards curiosity, a driving force for most living things. We enjoy novelty in the arts and our department celebrates this yearly during the Ann Arbor Art Fairs in July with the Chang Lecture on Art and Medicine. This will be our 8th year for it and our speaker will be James Ravin, an ophthalmologist at the University of Toledo. He was educated and trained here at Michigan and is co-author of a wonderful book The Artist’s Eyes. As you look forward to the summer, consider coming to the Art Fairs and stepping out of the heat late on Thursday afternoon (July 17, 5:00 PM, University of Michigan Hospital, Ford Auditorium) to hear Dr. Ravin.
  2. Curiosity drives discovery, a fundamental expectation of society for enterprises such as our university, our medical school, and our Department of Urology. We have been pretty good at discovery for a century of urologic practice, education, and research in Ann Arbor. Intellectual curiosity gets expensive, but it must be supported. A hundred years ago our curiosity was funded by the faculty themselves and the hospital. That is, some dollars from the practice of health care were turned to the academic mission of educating the next generation and discovery of new knowledge. After WWII, the federal government recognized the essential national priorities of education and research, thus federal funding came to dominate health care research. Massive structures were necessary to play in that important game of discovery. (Just look in our back yard at Med Sci I & II, the VA research buildings, Med Sci Research Buildings I-III, The Life Sciences Institute, BRSB, North Campus).
  3. Deliberate contraction of that national agenda and foolish sequestering have downshifted that funding, transferring more cost of maintenance of the physical and intellectual infrastructure to medical schools. This makes the picture bleak for today’s budgets, and bleaker for tomorrow’s discovery. The frost is lifting a little, perhaps as you look at Congress’s funding projections, but we are sadly below where we should be in terms of nations R & D. The paradox is that on one hand as we assign blame for the downshifting of research funding to the “limited resources” of our national wealth, we seem oblivious to the fact the wealth of nations and the health of nations derive from discovery. Thor’s hammer of sensibility will not be coming down on Washington anytime soon, so we need to live with this new normal and create a new paradigm of medical education and research, or rapidly shutter expensive buildings and repurpose talented researchers.
  4.  Politics and politicians that set the national agenda and policies are important to our self-interest. Courts have recently decided that influence from political action committees (PACs) should not only be protected, but even expanded. Therefore you and I cannot remain mere witnesses to the political game. We need to be open-minded to different ideas, but find and support niches that resonate with our interests. The AUA and ACS PACs represent our profession reasonably well and need our support. They are part of political life today and we can’t treat them as unseemly. Even more essential than those professional organizational PACs is M-PAC that represents our health system. The meager dollars it raises for regional political candidates gives the UM a seat at the table where political sausage is made. Yet from that seat, our voice is disproportionally stronger than our dollars. This is because of our intrinsic legitimacy (after all, the University of Michigan is not simply a self-interested business; as a university it is one of the few institutions that are specifically here for the tomorrow of our species). The purpose of education and research is to create a better tomorrow. The obvious legitimacy of our enterprise magnifies the effect of our lobbying. My friend Rick Bossard, a critical link between the University of Michigan Health System and the world of politics and policy, once quoted a prominent state of Michigan official as saying: “Show me all the data you want, but the only thing a politician understands is a story.” So please make 2014 a year to tell those stories. A few dollars from each faculty member will make a difference. (This plug and my plug for your support of the Micah and Noah Canvasser Mott Library are all I’ll ask of you this year in terms of external philanthropy).
  5. Last month I complained, quixotically, that technology and health care policy have gone beyond enabling to distorting the practice of medicine. I have no illusion that technology and standardization are essential in health care, but their applications are best carefully integrated into the next iteration of our model of health care, rather than legislated by Congress, regulated by disconnected agencies and states, or put in play by competing industries in the free market. It is an unsightly hodgepodge that is forcing the commoditization of medical practice, with a misguided belief that technology will solve the problems. Health care is becoming more expensive and less patient-centric in spite of the Orwellian rhetoric that puts this phrase in play. When this gargantuan apparatus eventually collapses, correction will be all the more difficult.
  6. Orwellian language brings to mind ICD-10, another story of our time. Few can doubt that to manage the complexities of modern diagnoses and new therapies, some consistency in language is necessary at national and an international level. That consistency has been achieved and regulated, but now to a fault. A Darwinian niche was filled in 1893 when Jacques Bertillon, a French physician, presented the Bertillon Classification of Causes of Death at a meeting of statisticians in Chicago. Five years later the American Public Health Association recommended adopting this system throughout North America, with periodic revisions to reflect new discoveries. The idea was embraced and in 1900 it became the International Classification of Causes of Death published as a small book. In 1948 the World Health Organization (WHO) took over the responsibility for this publication, expanding it to two volumes and including morbidity conditions, injuries, their causes, and mental conditions. That sixth revision (ICD-6) in 1949 was retitled – International Statistical Classification of Diseases, Injuries and Causes of Death (ICD). A ninth revision began at an international conference in 1975 and the International Classification of Diseases, Clinical Modification (ICD-9-CM with additional morbidity data) is used by the U.S. National Center for Health Statistics (NCHS) in assigning diagnostic and procedure codes for inpatient, outpatient, and physician office utilization throughout the United States. It was updated annually.
  7. ICD-10 Work on ICD -10 began in 1983 and is only now in the midst of implementation. This “new” system became ridiculously complex in its 3 decades of creation. It is a main reason we must abandon our beloved homegrown electronic medical record called CareWeb in favor of a clunky nationally-mandated product.  (See the article in New York Times Business Day by Pollack December 30, 2013: “Who knows the code for injury by Orca?”  Also, Utter et al in JACS 217:516, 2013: Challenges & opportunities with ICD-10-CM/PCS). The US ICD-10 CM has 68,000 codes. That is a lot of separate diagnoses to keep straight. Amazingly, a newer system ICD -11 is expected 2015 from the WHO. With up to 16,000 diagnostic codes ICD-10 is already in play world-wide from China to the United Arab Emirates. Hearing a rumor that the code had “7 different categories for bird bites” I went to ICD10Data.com and found even more detail than I’d expected.  Does this matter? I think so, for when a practitioner or office has to spend more time documenting a service (writing the note and looking up the codes for evaluation and management billing, etc.) than actually delivering the service, something is wrong. The infrastructure of personnel to manage this work in doctors offices, insurance offices, and government offices also siphon off huge dollars from actual delivery of care. Then too, if the documentation is inaccurate the bill at best is delayed or not paid, at worst the health care provider may be accused of fraud and incur penalties.
    Contact with birds
    The list goes on by the way to include chickens, turkeys, geese, ducks, and other birds. Holy cow – have ruminants also been considered?
  8. Current Procedural Terminology (CPT) codes describe medical, surgical, and diagnostic services and are maintained (and copyright-protected) by the AMA CPT Editorial Panel. CPT coding is similar to that of the ICD system except that the CPT identifies services rather than diagnoses. The Centers for Medicare and Medicaid Services (CMS) established the Healthcare Common Procedure Coding System (HCPCS) in 1978 as a voluntary system, but The Health Insurance Portability and Accountability Act of 199 made CPT coding mandatory. [Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs. Title II – the Administrative Simplification (AS) provisions – requires the national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.] The U.S. ICD -10 PCS has 76,000 codes for procedures. Human disease and its therapeutic options are complex, but does a diagnostic billing system for doctors offices and hospitals need that degree of detail? Who would have thought the elements of medical practice would be so complex?
  9. Berzelius Jumping from the complex elements of modern American healthcare structures to the relative simplicity of the truly elemental elements we come to Jöns Jacob Berzelius, (1779 -1848), a curious Swedish physician. His interests in chemistry dominated his career to the extent that he became one of the founders of modern chemistry along with Boyle, Dalton, and Lavoisier. Berzelius developed the concept of electrochemical dualism, created our system of chemical formula notation (e.g. H2O), and he originated terms including catalysis, polymer, protein, and isomer. You can thank him for the distinction between chemistry and organic chemistry.  He identified or isolated a number of elements including silicon, selenium, cerium, and thorium. Students in his lab discovered lithium and vanadium.
  10.  Thor Thorium, a naturally occurring radioactive element (Th -90) was discovered in 1828 by Norwegian priest and mineralogist Hans Morten Thrane Esmark, but isolated and identified that year by Berzelius.  Thorium is quite relevant to us. It has the atomic number 90 and is naturally radioactive (thorium-232). It is 3-4 times more abundant on earth than uranium in the Earth’s crust and is mainly refined from monazite sands. It has been considered as a nuclear fuel and India is leading in the pursuit of that application. It is used in high-end optics and scientific instruments. Thorium produces the radioactive gas radon-220 and its other secondary decay products include radium and actinium. The radiogenic heat of the earth largely comes from radioactive decay of thorium and uranium. Thorium was named for the Norse mythologic god, Thor – associated with thunder, lightning, protection of mankind, fertility, and healing. Clearly Thor’s persona encompasses some urologic undertone. The day of the week Thursday also derives from Thor. By the way, twenty years ago yesterday (February 6, 1994) the cartoonist Jack Kirby passed away at age 76 in Thousand Oaks, California. He was the imaginative “penciller” who drew Thor for Marvel Comics.
    Thorium
  11.  DoramadThe Auergesellschaft Company of Berlin in the 1920s had the novel idea of using thorium to make radioactive toothpaste advertised to “strengthen defenses” of teeth and gums (Doramad Radioaktive Zahncreme). A related healthcare novelty, Radithor, was a patent medicine manufactured from 1918 to 1928 by Bailey Radium Laboratories, Inc., of East Orange, New Jersey. The owner of the company and head of the laboratories William J. A. Bailey, a Harvard College dropout, advertised it as “”Perpetual sunshine and a cure for the living dead.” It didn’t contain thorium, but consisted of triple distilled water with 1 microcurie of radium 226 and 228 isotopes. The Vita Radium Suppositories, also including radium and sold around 1930 by Home Health Products of Denver were advertised for “weak discouraged men.” Radium Springs, Georgia is one of the state’s “Seven Natural Wonders.” After it was found to have trace elements of radium, it became a popular therapeutic spa.  Radium Springs, New Mexico also sits at the location of an old hot springs, although it never enjoyed national popularity as a resort. And then we must consider Radium Schokolade.Not all change and new technology has genuinely advanced the human condition.
    suppositories Radium
  12. If the winter doldrums are starting to get to you and you are starting to feel weak and discouraged, however, be cautious before reaching for that Doramad toothpaste to put a sparkle in your smile or those reinvigorating Vita Radium Suppositories to give you a literal kick in the butt. Novelty is important for us in that it challenges and entertains, but on the grand scale of social policy novelty should be embraced most cautiously. While ICD-10, HIPAA, the HITECH Act derived from compulsions to innovate, and while they may not be radioactive, I don’t think they have added to the greater good or happiness of mankind (except for a few very successful vendors). Enough said by me for now about ICD-10 and CPT coding, a “Thor subject” indeed.

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

David Bloom

What’s New December 6, 2013

Posted by

0

Matula Thoughts Logo1

The University of Michigan Department of Urology

3875 Taubman Center, 1500 E. Medical Center Drive, SPC 5330, Ann Arbor, Michigan 48109-5330

Academic Office:  (734) 232-4943   FAX: (734) 936-8037   www.urology.med.umich.edu   https://matulathoughts.org/

 

 What’s New December 6, 2013  

Looking at things: Autumn is over and 2014 is at hand. The continuing national drama and 2 stories: the Halifax tragedy and the florist’s tale. 

A monthly communication to the faculty, residents, staff, and friends of the University of Michigan Urology Family.

 12 Items, 4 Web Links, 9 Minutes

Fall

  1. Another season of interviews has passed as applicants from all across the country visited Ann Arbor to check us out for the residency class that will graduate in 2019. We held 4 full days of interviews with 2 dinners to meet the applicants and for them to see us. It may seem a long way away until 2019 when this cohort will step out into the world as trained urologists, but the time will pass in the blink of an eye. This is an incredible group of candidates with amazing life experiences, board scores, and talents. Our job will be to turn four of them into the best of the best of the next generation of urologists, and we are well qualified for that task, based on our history and our assets. For all the intensity of work they will encounter, I hope they will appreciate each passing season in our town. Seasons bring both an anticipation and reality of change that seems sharper here in Ann Arbor, than I noticed myself as a resident at UCLA in Los Angeles, not that I didn’t enjoy LA greatly. In some years the anticipation exceeds the actual physical reality, but this year the autumn actuality was crisp, colorful, and generally more lovely than expected. I hate to see autumn pass, but December is at hand and given general and personal good fortune for you and me, another lovely autumn will present itself in nine months. [Picture: Huron River looking east from Foster Bridge, mid-November]
  2. Interesting things happened on this day of the calendar. In 1768 the first edition of the Encyclopaedia Britannica was published. The U.S. Congress on this day in 1790 moved from NYC to Philadelphia before the southward migration ended in Washington, DC. In 1865 the Thirteenth Amendment to the U.S. Constitution banning slavery was ratified. (If you haven’t seen the new film, “Twelve Years a Slave”, that was based on a true story – you should.) The Halifax Explosion in Canada in 1917 was the largest man-made explosion prior to the development of nuclear weapons and until September 11, 2001 in NYC it was the largest disaster in North America with over 2,000 deaths and 9,000 injuries.
  3. What’s next in our national political and legislative drama?  I wish we could look to someone for a reasonable set of answers. Clearly, health care is a human right and reasonable access to health care of good quality is in the national interest. The national interest was served in 1965 by the Medicare/Medicaid laws (largely over the vehement objection of our professional groups). Health care has changed almost beyond recognition in the 50 years since Medicare/Medicaid in terms of science, technology, systems, and expense. So some new iteration of systemic legislation is a reasonable expectation.  As a sixth of the national economy, health care can’t be left solely to the “market” (which is far from free in any sense), nor can it be tinkered with federally without great care and deliberation.  The national web-based system of health care exchanges built by contractors on the cheap with unreasonable deadlines and other constraints was bad tinkering. The present set of systems, organizations, rules, and regulations related to health care must be made to work, or we will face a serious melt-down of health care and the national economy.
  4. Having mentioned the Halifax Explosion anniversary a little earlier, we can’t let it pass without more comment. However, it needs to be viewed in terms of what was going on in the world on December 6, 1917. The First World War had been raging in Europe since 1914 although here at home Woodrow Wilson had started his second term of office re-elected in large part for his record of non-intervention. Germany announced resumption of unrestricted full-scale submarine warfare in February of 1917, challenging American restraint. The decoding of a secret telegram revealed that Germany had invited Mexico to become an ally against the U.S. in exchange for the recovery of Texas, New Mexico, and Arizona. Doubt as to the veracity of the telegram evaporated in March when Arthur Zimmermann, Foreign Secretary of the German Empire, admitted he was the author. With the exposure of the telegram and the sinking of 7 of its merchant ships, the U.S. was provoked out of non-intervention and entered the war on April 6, 1917. Canada, of course, had been in the war from the start as part of Great Britain.
    Western UnionTelegram
  5. That morning of December 6, 1917 the SS Mont-Blanc was trying to enter the harbor of Halifax, Nova Scotia to join a slow-moving convoy to Europe, gathering in the basin of the harbor. The explosives on board the SS Mont-Blanc included TNT, picric acid, benzole, and guncotton. The ship had arrived from New York too late on December 5 for the evening deadline when the anti-submarine nets went up at The Straights leading to the harbor basin and thus had to wait to enter at first light the next morning. Harbor Pilot Francis Mackey had come on board and spent the night as guest of Captain Le Médec. So on the morning of December 6, moving at the slow speed of less than 1.5 miles per hour (.87 knots/hr) the SS Mont-Blanc headed northwest into The Straights on the Dartmouth side of the channel.
    map
  6. A Norwegian vessel, the SS Imo, chartered by the Commission for Relief in Belgium, had been in the Port of Halifax since December 3 enroute to NYC to pick up a cargo of relief supplies to bring back to Europe. The Imo was without cargo and high in the water, leaving her difficult to steer. She had refueled with coal in the Bedford Basin of Halifax Harbor and had intended to leave port on December 5, but its 50 tons of coal had arrived late in the afternoon and by the time the loading was completed the anti-submarine nets had been raised outside The Straights so the Imo had to remain in port that night. Captain Haakon From, an experienced Norwegian seaman and whaler, was anxious to get moving the next morning and headed out The Narrows along the Halifax side of the channel starting its journey to NYC. Proceeding at a speed in excess of the seven knot limit he encountered an American tramp steamer coming towards him (on the wrong side of the channel). For practical reasons the two captains, who knew each other, agreed to pass each other on their right sides, port-to-port (rather than the starboard-to-starboard convention of Article 18 of the 1910 “International Rules of the Road, Regulations for Preventing Collisions at Sea”). The Imo then found itself in the path of an oncoming tug and 2 scows that forced it even more off course toward the north side of The Narrows. This then brought the Imo directly into the path of the on-coming Mont-Blanc. The two captains saw the predicament and the Mont Blanc went to port and at the same instant the Imo reversed her engines. However, because the Imo was so high in the water, with its single 20 foot right-hand propeller and rudder partway out of the water, the ship had reverse thrust, tending to swing to the left (port) on forward motion and the right (starboard) if in reverse. The engines were cut, but the momentum of the two ships could not be reversed.
    Ships
  7. At 8:45 AM the ships collided at slow speed in The Narrows. The prow of the Imo went into the starboard hull of the Mont-Blanc causing a 9-foot gash into the No. 1 hold. As the Imo reversed its engines to disengage sparks ignited a fire with benzole spilled from some barrels crushed by the collision. The fire quickly spread out of control and the Mont-Blanc crew knew an explosion would be imminent. They fled the burning ship in lifeboats and the slack tide carried the empty ship to Pier 6, on the Halifax side of The Straight, where it beached at the foot of Richmond Street which was near the western end of The Straight. The fire continued, attracting hundreds of spectators, and at 9:04 AM the explosive cargo ignited. Mont-Blanc was completely blown to pieces, and the remains of her hull were launched 1,000 feet into the air. The pressure wave from the explosion flattened much of the city, bent iron rails, and snapped trees. Pieces of the ship landed all over Halifax and Dartmouth, the town on the other side of The Straight.  Some pieces of the ship traveled over four kilometres. One Mont-Blanc cannon landed 3.5 miles north of the blast site and the anchor shank landed 2 miles south. Today you can find these mounted where they landed as monuments to the disaster. A tsunami from the blast wiped out the community of Mi’Kmaq First Nations community in the Tuft’s Cove area. Hundreds of people who had been watching the unfolding drama of the ships were blinded by exploding windows. The disaster elicited a wave of volunteers from the United States, including Ernest Codman, in many ways the inspiration for modern day “outcomes research.” He had established a hospital constructed around his “end-result idea” but on hearing of the Halifax Disaster he closed his hospital doors and headed north to help. The Codman Hospital never reopened.
    Ships2Explosion
  8. The Wreck Commissioner’s Inquiry placed blame with the Mont-Blanc captain, harbor pilot, and the port’s executive officer – Royal Canadian Navy, Acting Commander F. Evan Wyatt. The men were immediately arrested and charged with manslaughter and criminal negligence. A Nova Scotia Supreme Court justice, however, found there was no evidence to support the charges and Mackey was discharged on a writ of habeas corpus and the charges dropped (15 March 1918). As the captain and pilot had been arrested on the same warrant, the charges against Le Médec were also dismissed, leaving only Wyatt to face a grand jury hearing. On 17 April 1918, a jury acquitted him in a trial that lasted less than a day. Le Médec returned to France and continued his career with the French Lines. His North American counterparts, however, found their careers ruined. Wyatt and his family moved to Boston where he worked in the merchant marine for a few more years. Mackey spent his life savings fighting for reinstatement of his pilot’s license, which he finally regained in 1922, but the stigma of the disaster tarred him and his family even after he died in 1961. Much was learned from the disaster, in terms of navigation safety, training, and medical response.
  9. Although catastrophe provokes change more urgently than tranquility it is not necessary to wait for the gigantic disasters of life to learn and improve processes. The many clinics and operating rooms of Michigan Urology are more complex than maritime passage in The Straights of Nova Scotia, and while the consequences of imperfection do not level a city like the Halifax Disaster, they can have substantial individual impact. Few human enterprises are perfect, but perfection must be our target. We try to learn and improve daily with tools such as PDCA (plan-do-check-act) cycles and Gemba walks.  Casual communication in the community also reveals opportunities to learn where we fall short and how to work better. This happened just a few weeks ago at home as we were getting ready for a Sunday brunch with residents and new faculty families. We do these in batches because our faculty, residents, and fellows in aggregate exceed our home footprint. Tom Thompson, friend and florist extraordinaire, was bringing over the flowers for the event and he was in exceptionally good spirits due to his new orthotics. I could relate to that, since like many people who work on their feet I know what plantar fasciitis (a similar problem) is like.  Additionally as a purveyor of health care for our Urology Department services and as of vice chair of our Faculty Group Practice I am very interested in other people’s experiences with our system at UM and with the systems of our colleagues regionally and around the country.
    Tom Martha
  10. Tom gave me permission to tell his story. He is a tad older than I am and he has had painful, non-diabetic peripheral neuropathy – exacerbated by his job on his feet all day. This has been going on for several years and it sounds similar to plantar fasciitis that affects many surgeon and OR nurses. Tom has seen some of our UM folks and had testing that made the diagnosis, but found no therapeutic relief from our clinics. One day, in his store, a local orthopedic surgeon, Robert Young, hearing of the problem, suggested a trial of foot orthotics. Tom pursued that lead and went to a UM clinic where a young health care professional came in with an entourage and asked: “What is your problem?” Now Tom is a pretty agreeable and mellow soul, but as a florist with a gift for “presentation” he found the question brusque and perhaps unnecessary given our highly touted electronic medical record. I agreed – that particular opening gambit is a suboptimal introduction of a healthcare provider (and an intimidating phrase) to a patient.
  11. I don’t want to draw too fine a point with this. The youngster in question clearly intended no malice and was probably wearing down at the end of a busy day. Maybe his feet hurt too. Ultimately, the blame for this little episode must come back to me, my fellow chairs, and our faculty. As teachers and role models, we are imperfect, but one would think the products of our instruction should be able to do better than Tom’s experience – which is neither isolated nor unique. The introduction, the conduct of a clinic visit, the ability to make a diagnosis, and the commitment to find a meaningful solution to a clinical problem are the “blocking and tackling” basics of our work in health care. For many of our young health care professionals those basics are eclipsed by economic and technical realities. Economic pressures from E & M coding, the HITECH Act, the ACA, and ICD10 direct more health care dollars to the corporate world – and distort every patient experience. The electronic medical record turns the ancient doctor-patient experience into an “encounter” with mandated electronic “check-offs” wherein the computer screen has become a surrogate for the patient and the “provider” becomes a stenographer. Anyway, I’m glad Tom is feeling better and still working, but I feel as though we could have done our jobs (educationally, professionally, and therapeutically) better.
  12. Looking forward, 2014 will be here soon enough. I had a productive mini-sabbatical last year with our A3 analysis and the Department of Urology benefited from John Wei’s term as Acting Chair. We will repeat the experiment this year with the next half of the mini-sabbatical when Stuart Wolf will take his turn as Acting Chair. The AUA will be in Orlando in May and we hope to see many friends of the department at our Nesbit Reception Sunday evening May 18 from 5:30-7:30 PM. An essential source of funds for our prostate cancer research is the Michigan Men’s Football Experience, and the dates for this have been fixed at June 4 and 5, 2014. This was the innovation of Dave Brandon and Jim Montie during the great coaching era of Lloyd Carr. Brady Hoke and his superb team have been developing and building that tradition. The Hoke coaching staff has been coaching our department in recruiting methodology and their teaching helped greatly in our urology recruiting this autumn. Next in the calendar comes the Ann Arbor Art Fairs with the Chang Lecture on Art and Medicine (Thursday, July 17 during the Art Fair at 5 PM), followed the next day by the Duckett and Lapides Visiting Professorships.  Our Nesbit Society Seminar is planned for October 9-11 when, as I predicted in item #1, autumn 2014 will be here in the blink of an eye.  So please pencil some of these into your new calendar as soon as you open it up.

Postscript notes. a.) Last month our internal weekly “What’s New” profiled a Part II update from John Wei our Director of Communications, Marketing, and Networking; Khurshid Ghani in the Endourology Division; Nina Casanova fellow in our Pediatric Urology Division as well as Lindsey Cox and Anne Suskind fellows in our Neurourology and Pelvic Reconstruction Division; and John Stoffel our Associate Chair for Ambulatory Urology Services on the ACU.  Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.  Recent award: Susanne Quallich was awarded the Arthur T. Evans Lectureship for her presentation on “Diagnosis and Management of Chronic Testicular Pain: State of the Science” at the Society of the Urologic Nurses and Associates 44th Annual Conference in Chicago last October.

b.) Nearing the end of the year we each get bombarded with requests for charitable giving. In fact, I send out a number of these on behalf of our department to support our research and education efforts.  You and your family have a few key organizations to support, but I’ll put in a special pitch to you now to consider two specific efforts. One of course is United Way (http://uway.umich.edu/), a community-based organization that fills many needs in our region. The other is the Micah and Zachary NICU Giving Library at Mott and the Micah Smiles Fund that has special meaning to our department and the Canvasser family. This project could use new picture books or any contribution that you might feel like offering. (http://www.annarbor.com/news/ann-arbor-family-starts-library-at-cs-mott-childrens-hospital-in-memory-of-infant-son/ and  http://givetomott.org/ways-to-give/current-fundraising-initiatives/micah-smiles/)

Best wishes, and thanks for spending time on What’s New this weekend.  Your comments are welcomed.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu

What’s New November 1, 2013

Posted by

0

Matula Thoughts Logo1

The University of Michigan Department of Urology

3875 Taubman Center, 1500 E. Medical Center Drive, SPC 5330, Ann Arbor, Michigan 48109-5330

Academic Office:  (734) 232-4943   FAX: (734) 936-8037   www.urology.med.umich.edu    https://matulathoughts.org/

 

 What’s New November 1, 2013   

Nesbit Society and Other Thoughts 

A monthly communication to the faculty, residents, staff, and friends of the University of Michigan Urology Family.

 31 Items, 1 Web Link, 15 Minutes

 1.  The autumn leaves are mostly gone, our PGY1s are well into their game, and our chief residents and finishing fellows are looking at their next stage of professional life. All these themes came together two weeks ago at our Nesbit Society Reunion. Although Hugh Cabot actually established urology at Michigan (circa 1919/1920), his trainee Reed Miller Nesbit, was the first formal section head from 1930 to 1968. Jack Lapides followed from 1968 to 1983 during which time his former resident and later colleague, John Konnak (Nesbit 1969 Trainee), spearheaded the Nesbit Society that formed in 1972. When Lapides retired in 1983 Ed McGuire came from Yale to become section head and brought me here from Walter Reed in 1984. Michigan Urology became an official department of the medical school in 2001 under Jim Montie, our first chair.

 2.  The Nesbit Society has a reunion and scientific meeting on campus in the autumn, usually around a football game in which, this year, Michigan prevailed after a challenging contest with Indiana. Additionally we have a reception at the spring meeting of the AUA, on Sunday night May 18, 2014 next year in Orlando. Membership is now at 211 active members (including our 3 new faculty members), 34 senior members, and 32 associate members. We have gradually been broadening the membership of the Nesbit Society to include not only our residency/fellowship alumni and our faculty, but also our UM undergraduates and medical students who found their way (inspired by Michigan Urology, one way or another) into the field. The Nesbit Society is an important bridge from our past to the future. We need to support that bridge, so if you missed the meeting this year, try to put it on the calendar in 2014 (October 9-11 when we will be playing Penn State).  If you don’t quite think you are “a member” but have even a slight interest in coming to a great CME event, a great tailgate/football game, and a dinner with wonderful friends and colleagues – drop me a note, put it on the calendar, and come as my guest.

3.  Three outside speakers and one colleague from our School of Business distinguished the program this year. Ray Costabile, Senior Associate Dean, Vice Chair and Professor of Urology at the University of Virginia spoke about his career in the U.S. Army and challenging work running “An Academic Medical Center on the Battlefield” as well as “Controversies in Andrology.” Both talks were crowd-pleasers. (Years back both Ray and I were at Walter Reed together). Jovan Ivchev, a friend of Michigan Urology for many years, gave “An Overview of Military Medicine in Macedonia and its role in NATO peacekeeping operations.”  Jovan is Head of the Military Medical Service of the Army of the Republic of Macedonia and he is an accomplished urologist and general surgeon.

4.  Dana Ohl had inserted an andrology theme into the Nesbit meeting that included his own superb talk and a terrific presentation of Rob Jackson [Nesbit 2012 and former fellow of Dana’s].  Rob is now in practice in Boise, Idaho. During his years at Michigan, with Julie and their children, he tried to visit each of our public parks and probably hit that mark or came very close. Ray Reilly, Professor of Business Administration at our Ross School Business spoke on “Managing your portfolio in turbulent times.” His pyramid of prudence (as I would describe his approach) was well-received by the audience, with an interesting counterpoint from our own Dr. Cheng-Yang Chang.

cerny

Joe Cerny [Nesbit 1962], Carl VanAppledorn [Nesbit 1972], Cheng-Yang Chang [Nesbit 1967]

Solomon Goh

Hugh Solomon [Nesbit 1980] and Meidee Goh [Nesbit 1998]

Wan Oldendorf

Julian Wan [Nesbit 1990] (President) and Ann Oldendorf [Nesbit 1992] (Secretary Treasurer)

Nesbit Attendees

Attendees at the Nesbit Society Meeting

5.  At Nesbit we also heard a number of first-rate presentations from our residents, fellows and faculty. I gave the usual talk on the state of the department, that is solid after a rocky 2 years (much like the rest of the world) and explained why we need a substantial clinical margin (the faculty’s “tax” for running an academic program with education, research, and leadership centered around our essential deliverable of kind and excellent patient-centered care) in addition to help from our friends in the form of philanthropy.  Medical research funding is shrinking. Ray Costabile was quick to note that the same pertains at his shop in Charlottesville: to get a dollar from the NIH has traditionally cost us a dollar-and-a- half. I expect very shortly (if not already now) we will revise that calculation and find it really takes more than two dollars to get one from the NIH.  Research and discovery are essential to our field and our species, and we have been lucky to have had relatively easy money from the government in the past, those days are gone.

6.  A similar story pertains for residency training (GME). Even with money we get from the Medicare-based funding of GME, we train more residents and fellows than the government pay supports. The bottom line is that our faculty practice and philanthropic base have been essential for the several million dollars we need each year to deploy the Michigan Urology mission of education, research, leadership, and that essential deliverable of kind and excellent patient-centered care. Michigan Urology has been doing this well for close to a century, even as rules, systems, and economics have changed. These things are changing again, faster and more substantially. Every iota of interest and support helps us, and every nickel contributed is stewarded wisely in support of our mission.

7.  At the Nesbit dinner Friday evening Betty Konnak graced us with her presence.  Dan Murtagh [Nesbit 1983] and his wife, Stephanie, (pictured below) joined us to celebrate his 30th class reunion.

Dan Stephanie

Dan reminisced about his residency training days with John Konnak:  to this day when he is doing a difficult case and has a moment of quandary he “hears” John’s admonitions “showing him the way.”  Brent Hollenbeck [Nesbit 2003] celebrated 10 years.  John Wei was awarded the 2013 John W. Konnak Faculty Service Award for his dedication to the educational, research, and service missions of the department. He was also honored this past week at the Faculty and Staff Awards Dinner on receiving the Dean’s award for Clinical and Health Services Research.

8.  At the Nesbit dinner we also recognized Ed McGuire along with his wife, Susan, for service to the department.  Ed was recruited to the University of Michigan as Professor of Surgery and Section Head of Urology in July of 1983 becoming Associate Chair of the Department of Surgery in 1988.  In 1992 he joined the University of Texas Health Science Center at Houston as Professor of Surgery, and Director of the Division of Urology one year later. He returned to Michigan in July of 1999 as Professor of Urology and head of the Neurourology and Pelvic Reconstructive Surgery Division in the Department of Urology (a position he served as head until 2007).  In 2007 he was named the Reed Nesbit Professor of Urology.  In the past few years he shifted his effort to the Ann Arbor VA.  On June 30 of this year Ed officially retired from the U of M and was granted Professor Emeritus of Urology status at the September Regents meeting.  We honored Ed by giving him a collegiate chair (the kind you actually sit in).  Ed will remain in our department as an active emeritus faculty and continue his work on the next volume of the history of urology, among other projects.

9.  On a larger palette, healthcare USA remains a work in progress, but overall it is far below its potential. Yes, we have some, (arguably most), of the high points of innovation and performance in the world, but we fall short in terms of distribution, equality, and systemic integration. Many people experience terrible personal hardship when they fall through the cracks between silos of turfs and systems. Economic hardship is rife as people fall through the economic cracks of health care – I’ve heard the figure that more than 50% of personal bankruptcies are related to catastrophic health care bills. If you suffer a million dollar health care catastrophe, your 20% copay can make you homeless.

10.  Bad press.  A recent front page NY Times article profiled a 78 year-old lady in Florida needing a partial denture. The bill was $5700 and the dentist gave her a “special line-of-credit” with a financing company. It was good news for the dentist who was paid up front. The lady was given a payment plan at 23% interest that would go to 33% (plus a $50 penalty) if a payment is missed.  Her minimum monthly payment of $214 takes a third of the Social Security check that she lives on. [Silver-Greenberg J. “Patients mired in costly credit from doctors.”  NYT Oct 14, 2013.  CLXIII p. 1] Of course dentists need to be paid fairly and of course many elderly people need dentures. But this common scenario doesn’t seem right – and notice that the caption of the article says “doctors.”  The public is increasingly unhappy with all health care professionals.

11.  The ACA – how is it working? The point to make is that the law is here, it’s not going away, and it is (in spite of its many problems) a natural progression of health care legislation on this country. The ACA has been in place and in play for over three years. It is certainly imperfect and contains mistakes, omissions, and glitches, but it is the third major installment of the federal determination of health care that started in 1935 with the Social Security Act, extended in 1965 with the Medicare/Medicaid Act, and expanded again nearly on a 30-year cycle in 2010. The law is an attempt to make health care accessible, affordable and accountable to patients. You can look at the law as a bridge between patients and health care, although perhaps it is more of a causeway constructed of various pathways of insurance carriers and federal programs. Whether you like it or not, it is here after due process, it fills many needs of the public, and it needs to be improved as it gets implemented. It made no sense to try to turn back the hands of time and hijack the national economy in the hope of reversing the law. The national model of health care that may have worked well enough at the end of the 20th century cannot be parbuckled.

12.  Clearly the roll-out of the sign-up phase for the health care exchanges was marred by immature, clunky, and poorly fashioned software products, but we understand that already well-enough in the daily work of health care especially here in Ann Arbor. Actually, if I have any overarching complaint it is with the HITECH law and ICD 10 that preceded the ACA, and mandated systems that have slowed down health care delivery, driven up costs, enriched a few companies beyond imagination, and turned provider-patient relationships into forced encounters tailored to satisfy federally-determined “meaningful uses.” A cover illustration from JAMA last autumn, drawn by a little girl observing her sister’s visit in a doctor’s office, tells the story better than ten thousand words. Notice the doctor’s position and attention. [JAMA, 307(23):2497, 2013]

crayon

13.   “What’s New”, that you are reading now, began over a decade ago in the Dean’s Office here at Michigan under Allen Lichter when faculty, and most other people on the planet, were becoming deluged by information. Heavy activation of the “delete” button was the only way to get home at night, and even then to get to sleep. The right index finger of Homo sapiens was developing more callus and bone density around the world wherever anyone had access to a computer. It seemed to us then that a single predictable message that filtered and digested a minute fraction of useful information from the 2.5 exabytes (2.5 x 1018) of data produced by mankind every day would be welcomed. In the Department of Urology, we have an internally-directed “What’s New” every week, targeted mainly to faculty and residents, but often filled with internal operational issues and intended as weekend “homework.” In these over the course of each year we hear from our divisions and our individual faculty members who produce their own editions of “What’s New.”

14.  On the first Friday of each month (such as now) “What’s New” has a broader message and distribution, going out to the entire department, alumni, friends, colleagues, and other curious souls who sometimes send me very welcomed thoughts of their own. One of the objectives of What’s New is to be an electronic mini-journal club. We each read a unique set of newspapers, magazines, journals, and books so I hope whoever produces one of these weekly issues will digest one or more articles, ideas, or factoids from the daily 2.5 exabytes at large and share them with the rest of us. As the email chain for “What’s New” got longer and longer we started also posting this as a “blog” at MatulaThoughts.org. We are still in the learning stage of the blog-o-sphere, and are finding our way in it, but we hope you come to find MatulaThoughts.org easier to access and read.

15.  Factoid of the day number one. On this day in 1957 the Mackinac Bridge opened to connect the two pleasant peninsulas of Michigan. This was then the world’s longest suspension bridge between anchorages. The main span is 3,800 feet, making it now the third longest suspension span in the U.S. and the 15th worldwide. However, the entire 8,614 foot bridge is the world’s third longest in total suspension and the longest between anchorages in the Western hemisphere. The maximum height above water is 552 feet. The Verrazano-Narrows Bridge, opened in 1964, has a span between towers of 4,260 feet, a maximum height of 228 feet. The Golden Gate, opened in 1937, has a center span of 4,200 feet, a span between anchorages of 6,463 feet, and a maximum height of 746 feet. Longer anchorage-to-anchorage spans have been built in the Eastern Hemisphere, including the Akashi Kaikyō Bridge in Japan (12,826 feet). But the long lead-ups to the anchorages on the Mackinac make its total shoreline-to-shoreline length of 5 miles longer than the Akashi Kaikyō (2.4 mi or 12,672 feet). Like most things, it all comes down to definitions and clarity when you talk about bridge lengths. The main span between towers, the distance between anchorages, and the shoreline to shoreline lengths are all quite distinct.

16.  The big three American suspension bridges. (The U.P. is still a bargain.)

a.  Mackinac Bridge $4.00 each way, daily traffic 11,600.

Mackinac

b.  Verrazano-Narrows. $15 each way, daily traffic 189,962.

Verrazano-Narrows

c.  Golden Gate. $5 northbound only (southbound no charge), daily traffic 110,000.

Golden Gate

17.  Interesting things happen under bridges and on the sea, and in that respect parbuckling is a word that entered my vocabulary recently. It refers to the righting of a disabled ship, the notable case being the Costa Concordia on September 17, an amazing feat of determination, strategy, technology, and teamwork. The hapless individual responsible for the disaster itself, namely the captain of the ship, recently went on trial in Italy. Is he just a scapegoat for larger business decisions of the corporate enterprise that employed him or was the responsibility for the specific misadventure his alone? Like most binary questions of business, the answer is split between the choices. His selection and the culture of the organization may have set the stage for the SNAFU (I love that old Army acronym), but unquestionably it was the captain at the end of the sad day who steered that ship into the ground.

18.  Parbuckling may expand in its meaning to encompass the concept of resurrecting an entity or enterprise that while perhaps iconic in its day may be flawed enough to prohibit survival in new Darwinian circumstances. The Titanic is another relevant maritime metaphor. Like the Costa Concordia it was an amazing piece of technology for its time with hundreds of thousands of parts and thousands of processes. However, an overconfident captain, faulty systems of command and control, and structural deficiencies led to disaster. Who actually was responsible in each case? We have yet to build a perfect system on which we can rely that does not require the human factor. Maybe you might think Voyager 1 and 2 might qualify as examples, but even they will run out of power one day, and likely needed some tweaking along their incredible journeys up to now. Parbuckling won’t save them when that power runs out, nor could it save the Titanic. Anyway, leadership matters.

19.  Factoid number two (you can use this one): cranberries and UTIs. A JAMA Clinical Evidence Synopsis by Jepson et al concluded that cranberry products are not associated with UTI prevention. This seems to explode an old belief of mine, although the authors qualify their claim that a lack of sufficient active ingredient or statistical powering may have influenced their analysis.  [JAMA 310:1395, 2013]

20.  Another useful factoid: anti-oxidant supplements are not associated with decreased mortality and beta carotene, vitamin E, and higher doses of vitamin A may be associated with increased mortality. This comes from another JAMA Clinical Evidence Synopsis. Bjelakovic et al came up with this conclusion after an analysis of 78 RCTs involving nearly 300,000 participants. [JAMA 310: 1178, 2013]

21.  Continuing the idea of the electronic journal club, I can’t mention JAMA without bringing up the October 16 issue that has two contributions from Michigan. First is a paper by Steven Katz, and Sarah Hawley from our Departments of Internal Medicine and Health Management and Policy. This Viewpoint piece is entitled: “The value of sharing treatment decisions making with patients. Expecting too much?” [JAMA 310:1559, 2013]  The authors dissect the idea of “shared decision making” (SDM). Like many simplistic solutions to complex problems, the unintended consequences may exacerbate the original problems. The authors conclude: “…too little is known about SDM and its outcomes to support its role in addressing the increasing concern about overtreatment and medical cost inflation.” In other words, let’s not be too quick in inserting the “health policy idea de jour” into legislation and funding methodologies. The experience and damage from HITECH should offer enough evidence to avoid helter-skelter and knee-jerk health policy formulation. You can hear Steven’s on-line interview at Online@jama.com.

22.  Also in that edition is an editorial by Preeti Malani from our Department of Internal Medicine “Preventing infections in the ICU. One size does not fit all.” [JAMA 310:1567, 2013]  This editorial responds to a paper in that same issue on a randomized trial in 20 hospital ICUs to see if gloves and gowns mattered at all in acquisition of MSRA or VRE. In this study of 26,180 patients health care workers in one cohort used gowns and gloves for ALL patient contact, whereas the workers in the other cohort used only “usual care” unless an individual patient had known infection with antibiotic resistant bacteria – in which case gowns and gloves were worn in compliance with CDC guidelines. The study, by Harris from the University of Maryland School of Medicine, showed no difference in outcome regarding MSRA or VRE acquisition. Preeti’s editorial advocates caution in interpreting the finding and tailoring any approach to “the epidemiology of specific ICUs and resources available.”

23.  The Lancet is another journal I try to skim with regularity (I depend on others to read the high-fluting New England Journal of Medicine) and as I was thumbing through the Sept 28-Oct 4 edition I found a strong imprint of the University of Michigan. John Birkmeyer and his group have two articles on “Variation in Surgery.” He is lead author of the first that studies regional variation in surgery [Lancet 382:1121] and senior author on Peter McCulloch’s paper on strategies to reduce variation in the use of surgery [Lancet 382:1130].  The first article is the source of the “cover quotation” that distinguishes most issues of Lancet: “A patient’s odds of undergoing surgery often depend more on where he or she lives than on clinical circumstances.” In the same issue of Lancet Regina Morantz-Sanchez, of our history department, has an article in “The Art of Medicine Section” on Mary Amanda Jones one of the rare early women gynecologists in the male-dominated world of surgery in the later 19th century [Lancet 382:1088, 2013].

24.  Scientific literacy 101: Nobel Prize in Physiology or Medicine 2013.  This went jointly to James Rothman (now at Yale – work done at Stanford, MMSK, and Columbia), Randy Schekman (a Howard Hughes Investigator, now at UC Berkeley – work done at Stanford and UC) and Thomas Südhof (also a Howard Hughes Investigator now at Stanford – work done at UT Southwestern) for discoveries related to vesicle traffic mechanisms in cells. The intracellular control of “cargo” is a matter of exquisite logistics, the term that United Parcel Services (UPS) has leveraged so nicely in its advertisements. While UPS and its sister organizations manage your Amazon purchases, our intracellular vesicles manage hormones, neurotransmitters, enzymes, cytokines, etc. getting each one to the right place, at the right time. Schekman identified three classes of genes that regulate this work. Rothman discovered the membrane docking and fusing mechanism that works via protein complexes. Südhof identified how “temporal precision” is achieved by calcium sensitive proteins that activate a zipper like mechanism at the outer membrane of a nerve cell. This is important in all parts of biology, but especially so in our area of neuro-urology.

25.  One of the things that bothered me about the significant recent legislation related to health care, including such things as HIPPA, HITECH, and ACA is that the voice of our profession was drowned out by input from large corporate interests of third party payers, hospitals, big pharma, and other large industries of health care. The big special interests, seem to have eclipsed out the interests of the “house of medicine.” Part of the responsibility for this situation lies with us insofar as I think most of us medical professionals have a skewed perspective on the business of lobbying – a distaste for it – and accordingly our profession has a very weak voice in Washington. We should get over the distaste.

26.  The Constitution protects even our weaker voices, relative to big corporate interests. This protection comes in the Bill of Rights with the First Amendment that secures five freedoms: those of speech, the press, religion, petition, and assembly.  The right to petition of government is essential to a democracy. Citizens have general interests and special interests. Those general interests such as life, liberty, and the pursuit of happiness apply to all citizens, but special interests need protection as well because, after all, we are all specialists of one sort or another whether plumbers, panhandlers, pianists, or pediatric urologists.

27.   Urologists have two important professional organizations. The most immediate is the AUA (American Urological Association) that was established in 1902. The ACS (American College of Surgeons) dates back to 1913. These organizations were formed to consolidate the professionalism and values of their members and to further their education in the changing world of science, technology, and healthcare. The public interest of these goals and functions is represented in their tax-exempt nature as 501c(3) organizations. However, such identification prohibits their ability to engage in the political activities of lobbying for their special interests by means of supporting political candidates. Accordingly, the ACS in 2001 and the AUA in 2002 set up political action organizations under the 501c(6) tax code. These PACs were established as bridges between the members of their professions and federal officials. By law individuals such as us can contribute up to $2,000 per year while the PAC can contribute $5,000 per candidate per election cycle. Only the members of the AUA and ACS can contribute to these two PACS. The AUA-linked organization has recently reached the million dollar level of total annual funding while the ACS group is at about the $600,000 level. Although the scale of these PACs may seem small, they have a relatively larger impact in the halls of Congress because of the very nature of their representation of finite groups of professionals. Representatives are receptive to these authoritative professional groups. Interestingly – the UM Health System PAC representing our enterprise at home has less than a “$12,000 yearly voice.” You’d think it could be stronger.

28.  To me, the ACS political committee represents our general interests as surgeons, while the AUA political arm represents our special interests as urologists.  Both sets of interests are compelling and certainly overlap. While the ACS may, for example, lobby for standards of trauma units, GME funding, etc. the AUA political group might focus on such specific things as constraints on PSA usage, lithotripter deployment, and guidelines implementation. All these things and many more represent legitimate objectives of not only the professional aspects of urology, but just as well and even more importantly of the needs of patients with genitourinary conditions.  The aligned interests of these two conjoined groups, urologists and patients, are nowhere represented better anywhere else. Still, the involvement of surgeons and urologists in these two agencies is sparse – only 3.5% of ACS members and somewhat better for the AUA membership in its organization UROPAC. In contrast to the Mackinac Bridge the tariff on our bridges to federal legislation is up to an individual’s discretion up to the legal limit of $2,000 per year.

29.  Healthcare exchanges, ACOs, and direct business-health systems bridges. These new things are replacing the traditional individual insurance-based/employer-supported form of health care. One form or another of these experiments in health care delivery was bound to happen with or without the Affordable Care Act. Some prominent direct business-health systems bridges include Walmart and GE. Walmart and Lowe’s joined the Pacific Business Group on Health Negotiating Alliance to create the Employers Centers for Excellence Network that will offer no-cost hip and knee replacement for more than 1.5 million employees and dependents at Johns Hopkins Bayview, Kaiser at Orange County, Mercy Hospital in Springfield, MO and Virginia Mason Clinic. Other similar bundled payment direct contract may occur with Cleveland Clinic, the Mayo Clinic and Geisinger Clinic to provide care for employees with specific higher end specialty needs.

30.  Close to halfway up towards the Mackinac Bridge you might stop in the territory of MidMichigan Health, a quality healthcare system with a number of links to Ann Arbor. Those links have been strengthened by a significant affiliation that is being developed through an organizing council with 8 members of each institution. Furthermore, 2 members from UM have joined the MidMichigan Board, these being David Spahlinger, our Senior Associate Dean and leader of the Faculty Group Practice, and Doug Strong, our Chief Executive Officer. An oncology council, a heart and vascular council, plus additional collaborations in Ob/Gyn, Neurosurgery, Pathology, Radiology, Telemedicine, IT, Palliative Care, and Case management are already in play.  Credentialing/privileging standards plus quality/safety systems are also being brought together. We expect this relationship to improve both health systems.

31.  Last month our internal weekly “What’s New” profiled Mike Kozminski in the General Urology Division; Florian Schroeck and Paul Womble, fellows in the Urologic Oncology Division, and an update from John Wei our Director of Communications, Marketing, and Networking.  Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.  Also at the recent AUA North Central Meeting we had several people win awards.  Florian Schroeck had two awards: (1) Traveling Fellowship Award of the North Central Section of the AUA for the manuscript entitled “Regional Variation in Prostate Cancer Quality of Care” and (2) Best poster in the Outcomes / Socioeconomics poster session for the abstract entitled “Technology Diffusion and Diagnostic Testing For Prostate Cancer.”  Miriam Hadj-Moussa, HO3, won 1st place in the Bladder Malignant/Stone Disease/Endourology Poster Session for the abstract “Outcomes following radical cystectomy for bladder cancer in patients under 60 years old.”  John Stoffel was selected as one of the scholars for the 2014 AUA/EAU Academic Exchange Program.

Best wishes, thanks for spending time on “What’s New” this first weekend of November. Your comments are welcomed.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu

What’s New October 4, 2013

Posted by

0

The University of Michigan Department of Urology

3875 Taubman Center, 1500 E. Medical Center Drive, SPC 5330, Ann Arbor, Michigan 48109-5330

Academic Office:  (734) 232-4943   FAX: (734) 936-8037   http://www.urology.med.umich.edu    https://matulathoughts.org/

Matula Thoughts Logo1

What’s New October 4, 2013

A monthly communication to the faculty, residents, staff, and friends of the University of Michigan Urology Family.

Michigan Traditions – Kindness, heart, healthcare, kudos,

and other news.

22 Items, 2 Web Links, 12 Minutes

1.  Fall

Autumn is at hand, with a solid football season in play and our Nesbit Alumni weekend coming up. The department is doing well as this new fiscal year has begun and our calendar year starts to enter the home stretch. It was a busy summer and a crazy September given the apparent usual Mott effect of added patients. In the middle of the month I drove into Kerrytown for a cup of coffee with colleagues and after parking I dutifully was putting coins into the meter when a car paused alongside me and the driver opened the window to tell me: “It’s Sunday, you don’t need to feed the meter.”  It was a nice and random act of kindness. His heart was in the right place and it made me think of a book I read during my mini-sabbatical (Skip Campbell gave it to me, undoubtedly because he thought I could use the lesson and I truly did need it). The book was “The Power of Kindness” by Piero Ferrucci and was an easy read yet powerful and incisive. It pointed out that for most of us our heart is in the right place (anatomically and socially), although our self-absorbed lives and necessarily selfish interests often tune it out of our standard operating systems. Ferrucci’s lesson in kindness is an important “app” that we all need to install and refresh.

2. We had a retreat last month, the second in 2013, but this was entirely run by our younger faculty.  The retreat was called “Marketing, Branding and Social Media at Michigan.”  The faculty in charge assembled a great lineup of presenters and the keynote speaker was Ari Weinzweig on “Zingerman’s Community of Businesses: 3 Decades of Making a Difference.” The Zingerman’s Family of Businesses is a huge local success story, with a sustainable business plan, a culture of customer service raised to a whole new level, superb employee engagement, and a thoughtful holistic and precise strategy.  We have much to learn from Ari.  Coming soon as a result of this dialogue is a new and much improved website for our department.

Ari Julian Kate

Ari Weinzweig, Julian Wan, and Kate Kraft [Photo by Gary Faerber]

3. Our PGY-1s are well immersed in their first step of residency training going from their undifferentiated pluripotent stem cell state as new medical school graduates on a journey of specialization into urologists over the next 5 or more years. We hope this differentiation into specialists won’t impact their lifelong expression of kindness and curiosity although we know this happens to some specialists (rarely urologists). Our PGY-1s will finish in 2018, the 99th year of Michigan Urology, by my measure from the time Hugh Cabot brought modern urology to Michigan.  The tradition from Hugh Cabot and his trainee Reed Nesbit is long and great. With the Nesbit Society annual meeting approaching this is a good time to mention that we are putting the production of the next edition of our departmental history on the front burner.

4. Imagine my surprise the other week when I was looking through Science magazine and I found a picture of Scott Tomlins, our joint faculty member with the Department of Pathology.  It was not so long ago that Scott was one of our Michigan MD – PhD students considering residency choices. He picked well, selecting UM Pathology and his work with Arul Chinnaiyan, also a joint member of our department. Their team made a big discovery a few years ago, related to two normal human genes. One gene called TMPRSS2 is normally turned on in the prostate, while another called ERG is normally turned off. When, abnormally, the two genes fuse – something that the team found happens in about half of all prostate cancers – ERG becomes turned on and this drives cancer formation. From this observation, they have developed a urine test that can detect a product of this gene fusion. [Science 341:973, 2013]  Potentially, targeted therapy could follow.

Tomlins CEO

Scott Tomlins with AAAS CEO Alan Leshner [From Science: 341:973, 2013]

5. Nesbit Alumni Refresher. A new cohort of residents has stepped into the long maize and blue line of the Michigan Urology family that actually began under Hugh Cabot when he brought Reed Nesbit and Charles Huggins to Ann Arbor.  Cabot was busy, building the Michigan surgery department, the new hospital, and being dean in his first 6 years, and didn’t step into urology GME until 1926.  Formal residency training began under Nesbit and it is for him that our urology alumni group is named. We currently have 279 members consisting of 176 active members, 34 senior members, 32 UM Urology faculty, 15 joint faculty, 8 fellows, 20 residents, and 4 associate members.  Whereas meetings used to occur on alternate years, now they take place yearly and our 28th one is coming up.  The meeting is not just a scientific one, but a social one as well. The social aspect is essential.  Residency and fellowship training constitute the longest and most intense single educational interlude anyone will likely experience and it tends to bind most participants together tightly.  If careers and families inevitably create some drift of individuals, the Nesbit Society affords opportunity for reunion and reconciliation during careers and after them. Officers this year→ President Julian Wan [Nesbit 1990], Secretary/Treasurer Ann Oldendorf [Nesbit 1992], and three Directors David Bloom, Surendra Kumar [Nesbit 1981], and Dana Ohl [Nesbit 1987].

6. I was out of town for the Dean’s State of the School talk last month and went to the web site to see it.  [http://medicine.umich.edu/medschool/about/news/view-dean-woolliscroft%E2%80%99s-2013-state-school-address]  Dean Woolliscroft spoke of the challenges we face in this new resource constrained era of academic medicine.  This is the 4th era for our Medical School, the first being the period of focus on medical student education (1850-WWII), the second was the period of federal investment in research (WWII-1965), the third period was shaped by the expansion of clinical federal funding from Medicare and Medicaid in 1965.  This new era is one of resource constraint related to slowing of federal support of research and clinical care, increased regulatory constraints, and competitive pressure from aggregating large systems.  One could argue that this is an era of mission equilibration as the dominant federal funds that support research, clinical care, and education seem to  be shrinking significantly (era 4).  Perhaps this became most evident with the world economic crisis of 2008.  Research (era 2) and clinical care (era 3) come into balance not only with each other but with the basic unfunded educational part of our mission that started in era 1.  The Dean nonetheless painted an optimist picture of Michigan’s future based on our collective engagement, citizenship, and collaboration to preserve our mission and existence in the new era.

7. Medicare and Medicaid Update. We had talked about this before, but it’s time for a refresher. These entities came out of the Social Security Amendments of 1965, a bill signed by LBJ on July 20 as part of his Great Society era, an important testimony to the power of kindness of a nation. The AMA opposed the legislation until it was enacted and then cooperated in the implementation. The law basically consisted of 2 amendments to the 1935 Social Security Act. Title XVIII was Medicare – consisting of Part A which provided hospital insurance for the aged and Part B which provided supplementary medical insurance. Since then Medicare has acquired a Part C (Medicare Advantage which was formerly known as Medicare + Choice) and Part D (a prescription drug coverage).  Title XIX was Medicaid – providing for the states to finance health care for individuals at or close to the public assistance level with federal matching funds.

8. Medicare is a federal insurance program mainly for people over 65 and Medical bills are paid from trust funds that those covered have paid into. It also serves younger people with specific disabilities, particularly end stage renal disease and ALS. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is basically the same everywhere in the United States and is run by the Centers for Medicare & Medicaid Services.  Part A is funded for by a portion of Social Security tax. It helps pay for inpatient hospital care, skilled nursing care, hospice care, and other services.

9. Medicaid is a federal-state means-tested assistance program and medical bills are paid from federal, state and local tax funds.  Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States.  It serves low-income people of every age and is managed by the states. Patients usually pay no part of costs for covered medical expenses. It varies from state to state and is run by state and local governments within federal guidelines. Each state has broad leeway to determine eligibility and states are not required to participate in the program, although currently all do. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Medicaid payments assist nearly 60% of all nursing home residents and 37% of all childbirths. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. In 2009 Medicaid provided health care for approximately 50.1 million Americans and about one of every five persons in the U.S., were enrolled in Medicaid for at least one month that year. The Children’s Health Insurance Program (CHIP) provides coverage to 8 million children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage. Supplemental Security Income (SSI) disability benefits are for adults or children with a disability who qualify for income, resource and living arrangement requirements. Although the standards for determining disability are the same as for Social Security Disability Income (SSDI), people are not required to have paid Social Security taxes to qualify for SSI; once they qualify for SSI, they are also eligible for Medicaid.

10. The Affordable Care Act Update. In case you forgot, the ACA, passed into law March 23, 2010, sets out comprehensive changes that are already underway but go into high gear in 2014.  In summary, in 2010 a Patient’s Bill of Rights went into effect to protect patients from abuses of the insurance industry and additionally many cost-free preventive services were offered. Other consumer protections included elimination of lifelong limits on coverage, prohibition of rescinding coverage, prohibition of denial of coverage to children with “pre-existing conditions”, and help with appeals of corporate decisions. Small business tax credits became effective in a first phase. New incentives were created to rebuild the primary care workforce. States were offered matching funds to cover more people on Medicaid.  In 2011 Medicare patients were slated to get certain preventive services for free and receive 50% discounts on brand name drugs in the Medicare “donut hole.”  In 2012 value-based purchasing, linking payment to quality outcomes, was established in traditional Medicare. Accountable Care Organizations (ACOs) began to form that year and standardized billing requirements were initiated. Federal health programs were required to collect and report disparities-related data.  In 2013 new funding was provided to state Medicaid programs that cover preventive services at little or no cost. The law established a national pilot program to encourage payment bundling. Open enrollment in the Health Insurance Marketplace was set to begin October 1 of this year (three days ago) and will go to March of 2014.

11. One key goal of the ACA was to fix the unconscionable problem we had in this country of 47 million uninsured people. The latest estimates I’ve seen are that in spite of this gargantuan law, the number of uninsured will only drop to 31 million.  In 2014 new consumer protections will be put in place including prohibition of discrimination due to “pre-existing conditions”, elimination of annual limits on coverage, and ensuring coverage for patients in clinical trials. Quality improvement and cost reduction factors in the 2014 step include tax credits for people with income between 100% and 400% of the poverty line who are not eligible for other affordable coverage. A Health Insurance Marketplace should be available in 2014 and the small business tax credit second phase will be implemented: for qualified small businesses and small non-profit organizations the credit is up to 50% of the employer’s contribution to provide health insurance for employees and there is also up to a 35% credit for small non-profit organizations. Access to affordable care will be promoted in two ways.  One: increasing access to Medicaid – Americans who earn less than 133% of the poverty level (approximately $14,000 for an individual and $29,000 for a family of four) will be eligible to enroll in Medicaid; states will receive 100% federal funding for the first three years to support this expanded coverage, phasing to 90% federal funding in subsequent years. Two: under the law, most individuals who can afford it will be required to obtain basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans.  If affordable coverage is not available to an individual, he or she will be eligible for an exemption.

12. In 2015 it is intended that physicians will be paid (from Medicare and Medicaid) based on value not volume. A new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide “higher value” care will receive higher payments than those who provide “lower quality” care. This will be a fascinating experiment, although not one that I think should be run without far better understanding of what “higher value care” means and detailed analysis of the effect on health care at the individual level and the health care market. We certainly need to reform the American health care enterprise, but this sector of our national economy employs one in six people and affects the care of everyone so experimental solutions should be applied with great caution and prudence.  The risk to the nation’s health care and the economy as a whole is massive.  We can’t afford to continue on the previous trajectory, but we also can’t afford to crash.

13. Last month I spoke of the loss of KAL 007 due to a trigger happy, nervous, and unkind Soviet military pilot. This catastrophe took down one of our Michigan Nesbit alumni, Larry McDonald, who had been a passenger on that ill-fated commercial flight.  Coincidentally on this day in 2001 another commercial flight, Siberian Airlines 1812, crashed into the Black Sea, killing all 78 people on board (12 crew, estimated 66 passengers). Since this was just a month after September 11, terrorism was suspected. The plane, a Tupolev Tu-154, was enroute from Novosibirsk to Tel Aviv. The CIA reported that the crash was due to an errant S-200 surface to air missile fired by Ukrainian Air Defense Forces from the Crimean coast likely by some other nervous character with a firing switch. Russia denied that possibility.

14. Comments from Dick Lyons, a great name in the history of urology and a colleague of Nesbit and Lapides.  Dick is retired in Napa, in his mid 90’s and is a faithful reader of “What’s New.”  Responding to last month’s edition and the McDonalds he said: “I knew Harold Sr. better than most. One day on a visit on the way back from AAGUS, we had a long talk and I asked him how many TURs he would do in a day during the War when he was almost alone in town. He operated standing, by the way. He said ‘Eight or ten.’ He must have been a whizz, doing that many a day, and he had only a single resident, usually from the islands below. I asked how he slept, and he didn’t understand the question. My point was to do that many and not have a troublesome bleed seemed miraculous to me. No room for skepticism. The man was better than good.  He always was sad and disturbed about not being in the AAGUS.  But it seemed clear why. In any discussion, Harold would stand up and tell all that he had already mastered the subject in question, and he was correct and honest. I would have loved to partake of his knowledge and experience. But the egos got their wishes and kept him out. It’s tough to always be one-upped by someone who had really done it and I decided to test him. I had a urethral caruncle or was it a partial prolapse, in a black youngster…So I gave him call, asking what he would do. Wonder of wonders, he said ‘I don’t know. Never had one’ I told him that I, in the office simply strangled it with a tie, and it dropped off in a day or two-just common sense of course. But now I knew without doubt that Harold was an honest man. He admitted he didn’t know everything and I [therefore found that] had that rarity, a wonderful, exciting, probing, curious, older friend. There’s more to his story, for this was a lively family, at the least. He died of a broken heart … That is another heart rending story.”

15. Things aren’t always right. Sometimes, if you will forgive an anatomic pun, the heart is aberrantly in the “right” place, that is on the right side. Situs inversus was first reported in 1788 when students at the Hunterian School of Medicine showed their teacher, Matthew Baillie, a cadaver with the liver on the left side and heart on the right. Baille, a nephew of John & William Hunter, was a physician at St. George’s Hospital and specialist in morbid anatomy.  He died of TB in 1823. Carl Zimmer wrote an interesting report on this historic moment. [Carl Zimmer, Growing Left, Growing Right. NYT June 4, 2013] Actually, Leonardo da Vinci (1452-1519) had observed and drew dextrocardia much earlier but didn’t “report” his finding publically. The Baille story is even more interesting due to the investigative skills of Wendy Moore, author of The Knife Man, a great biography of John Hunter, the founder of scientific surgery. Baille kept most of Hunter’s notes after his death and is believed to have plagiarized so much from his uncle’s prodigious work that Baille burned the notes late in his life to hide the plagiarism. The observation of dextrocaria, however, seems to have been legitimately that of Baille.

16. Situs inversus refresher.  This is autosomal recessive, although it can be X-linked and there is a 5 –10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels.  (Curiously the incidence of congenital heart disease is 95% in situs inversus with levocardia.)  Individuals with primary ciliary dyskinesia have a 50% chance of developing situs inversus and when they do this is called Kartagener Syndrome. In the absence of congenital heart defects, most individuals with situs inversus who do not have Kartagener Syndrome are phenotypically normal (about 1 in 12,000) and can lead normal healthy lives. One example is Randy Foye an American professional basketball player currently of the Denver Nuggets of the NBA who has situs inversus with apparently no functional significance. He played collegiately at Villanova University and was selected in the 2006 NBA Draft by the Boston Celtics, immediately traded to the Portland Trail Blazers, and later traded to the Minnesota Timberwolves. He was just 30 years old at the end of last month and seems to have done pretty well in spite of his anomaly. We have full confidence that Foye and his similar anatomically distinct brethren are kind by default since their hearts are always in the right place.

17. Since we have been discussing puns and anatomy I can’t let the day go by without mentioning that it caught my eye that Oct-4 is the term for a transcription factor that is initially active in the oocyte but remains active in embryos throughout the preimplantation period. Oct-4 expression is associated with an undifferentiated phenotype and tumors.  Oct-4 can combine with Sox2, so that these two proteins bind DNA together.  Sox 2 is important to us urologists because it is actually SRY (sex determining region Y)-box 2, a transcription factor essential for maintaining self-renewal, pluripotency, of undifferentiated embryonic stem cells. The Sox family of transcription factors plays key roles in many stages of mammalian development.  Sox2 maintains embryonic and neural stem cells and may be critical for induced pluripotency, an emerging area of regenerative medicine. Mouse embryos that are Oct-4-deficient lose pluripotency and differentiate into trophectoderm. Therefore, the level of Oct-4 expression in mice is vital for regulating pluripotency and early cell differentiation since one of its main functions is to keep the embryo from differentiating. So much for the interwoven story of mice and men, for now.

18. The 3rd Annual James E. Montie Visiting Professorship was held on September 20 with W. Marston Linehan, MD, Chief of Urologic Oncology Surgery and the Urologic Oncology Branch at the National Cancer Institute in Bethesda.  Marston gave a great talk on “Targeting the Genetic Basis of Kidney Cancer, a Metabolic Disease.”  His extraordinary life’s work at the NCI has revolutionized our understanding of kidney cancer with its variants and pathogenesis.  I have several great friends who have benefited enormously from Marston’s work.

Linehan

Marston Linehan lecturing [photo by Todd Morgan]

Linehan VHL Dinner

VHL Family Alliance Benefit Dinner honoring Jim Montie [photo by Todd Morgan]

19. New faculty have joined the Urology Department.  Mike Kozminski [Nesbit Alumni 1989] will be working part-time with us here in Ann Arbor and Chelsea in the general urology clinic while he still maintains a practice at Phoenix Urology of St. Joseph, Missouri.  He has four sons.  Michael is a third-year resident here, Christopher escaped the medical world and is a comedic writer in Chicago, David is in our Medical School, and Andrew is at Northwestern senior pre-med.  Khurshid Ghani just completed a fellowship in Robotic Surgery at the Vattikuti Urology Institute at Henry Ford Hospital with Mani Menon.  He will be seeing patients at the Ann Arbor VA.  Daniela Wittmann, a social worker in our department, recently received her PhD from Michigan State University and now holds an appointment on our faculty as an Assistant Professor.  Welcome and congratulations!

20. Congratulations to Susanne Quallich (along with Cynthia Arslanian-Engoren) for winning 1st Prize Poster on “Chronic Testicular Pain: An Integrative Literature Review” at the 2013 UMHS Nursing Poster Session held last month.  Also John Wei will be honored later this month by the Medical School with the Dean’s Award for Clinical and Health Services Research.  Julian Wan is beginning his term as Chair of the American Academy of Pediatrics Section on Urology and was just named as one of the editors of the Journal of Urology.

21. Our Taubman II Ambulatory Care Unit has had two terrific leaders. Jerilyn Latini got it up and running very successfully at the start, and since she left John Stoffel has continued the pattern of excellence and leadership. Earlier this week he held a mini-retreat and gave an update on the ACU and his compelling vision. The ACU saw about 13,000 patients last year and its 34 FTEs support 20 providers. Four key metrics for the ACU are the current areas of focus.  The first is a matter of accessibility – trying to get at least 80% of new patient visits to occur within 4 weeks. The second is moving the patient into a room within 15 minutes (this metric is identified on our gemba walk by little racing cars on the visual board). We have been quite successful. Metric #3 is that of having visits completed in 60 minutes (90 minutes for our NPR patients. Previously we had about 80% success in this, although the challenges of MiChart have dropped this to around 50% for now. The final metrics are related to having nursing calls answered live and all problems addressed within 24 hours.

Malissa Stoffel Standiford

Malissa Eversole, John Stoffel, and Connie Standiford

Call Center

Early audience attendees

22. Last month our internal weekly “What’s New” profiled Brent Hollenbeck with updates as the Associate Chair for Research; Fellows Abdulrahman Al-Ruwaily, Chad Ellimoottil, and Sara Lenherr from Health Services Research; and an update from Jeff Montgomery head of urology at the VA including comments of Khurshid Ghani.  Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.

Best wishes, thanks for spending time on “What’s New” this weekend, and we look forward to seeing many of you at the Nesbit Society meeting.  If you can’t make it this year, consider joining us in 2014.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu