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/

1.    Academic medicine revolves around a lovely cycle. This cycle is distinct from a fiscal cycle that is generally not so pleasant, although the two are keenly intertwined. The financial margin of clinical care has supported the academic cycle for the past century if not longer. Some health systems have been managed so well that they provide large and even huge financial margins that can be reinvested in the academic mission although that has not been a big part of our history in Ann Arbor.  Those large margins are under attack from some, such as Charles Grassley in the Senate, who rightfully question the “not-for-profit” status of organizations with multimillion dollar CEO salaries plus bonuses, corporate jets, and all the other accoutrements of the “for profit” world.  While the “for profit” sector normally pays taxes, the social good of not-for-profit businesses is the justification for sparing them routine taxation.  On the other hand, those “normal” taxation responsibilities are regularly evaded by the corporate world via legal loopholes cleverly placed by self-interested legislators and lobbyists. As Captain Renault, played by Claude Rains in the film Casablanca, said with great irony: “I’m shocked, shocked to find that gambling is going on in here!” (as a casino worker walks up to the captain with a wad of money and says: “Your winnings sir.”).  Anyway, the world is changing and new fiscal reality threatens academic medicine.

2.    A recent Wall Street Journal article exposed the large mark up of expensive drugs purchased at discount by some educational institutions. This has been one way some institutions have been able to achieve those grand margins at the end of the fiscal year. The Time magazine single-issue-exposé by Steven Brill this past February, tells this story well and in great detail. We at Michigan have not been so clever, perhaps even to a fault if you look at our meager margins, but that is another story, for another day.

3.    Academic medicine’s cycle, although entwined with fiscal reality, has distinct cultural mileposts. We begin (coincidentally with the fiscal year) when new residents (interns or postgraduate year-one trainees – PGY1’s) start their work, usually unceremoniously around July 1. The next step is the White Coat Ceremony, when entering medical students formally began medical school and receive symbols of their new profession – short versions of the white coat and a very good stethoscope. We started the stethoscope program for incoming students around ten years ago and between generous donors and the clinical departments and faculty come up with the $25,000 to buy the top grade stethoscopes each year. This event and gesture should be especially meaningful for urologists because the stethoscope, after its invention in 1816 by Laennec in Paris, replaced the urological matula as the symbol of physicians. (For a refresher on matulas see our blog MatulaThoughts.org.)

4.    This year the White Coat Ceremony was held Sunday, August 4 in Hill Auditorium.  This and Graduation are the bookends of the medical school experience and they are wonderful events – well worth experiencing or re-experiencing from time to time even if you are a seasoned physician or anyone else in the Michigan Urology Family.  Family, in fact, was much of the theme of the White Coat Ceremony.  Most if not all entering students had family members present who often vigorously cheered as their son or daughter announced his or her name, hometown, and college.  The student then crossed the stage where the Dean helped them put on a white coat and faculty members presented each one a stethoscope.  Dean Jim Woolliscroft talked about enlarging importance of “The Team” in health care, echoing Bo Schembechler’s cry for “The team, the team, the team!”  President of the Medical Center Alumni Society (MCAS), Bob Evani (UMMS MD 1986) also talked of “family” – emphasizing the family of this particular class of 2017 and the family of MCAS. Michigan Urology with its Nesbit Society is our specialty team, a form of the team that we understand especially well in Ann Arbor.

5.    MCAS. One unusual and excellent thing that we have here at Michigan is the Medical Center Alumni Society. Whereas in most other medical schools the alumni are considered graduates of the medical school specifically, here at Michigan MCAS embraces the residency graduates equally and vigorously. This makes great sense in that we have somewhere around 700 medical students at a time and well over 1000 residents simultaneously. Furthermore, the medical students are here for usually 4 years, but residents average more than that time, many are here twice as long or longer. This has been one way that the University of Michigan, in aggregate, can probably boast the largest and most active university alumni in the world.

6.    Labor Day, a U.S. federal holiday since 1894, celebrates workers.  The triggering event for the unanimous vote by Congress to institute Labor Day was the wildcat Pullman Strike. The massive boycott that grew affected most rail lines west of Detroit and led to sabotage, riots, $80 million in property damage, and at least 30 deaths largely at the hands of military troops and U.S. Marshals. President Grover Cleveland, who had stepped in earlier to end the strike and called in the federal troops when an injunction to cease the strike was ignored, signed the holiday into law just 6 days after the strike ended. Labor Day this past Monday 119 years after its inception was a nice break from clinic for me and is for all of us a pleasant way to mark the end of summer and prepare for the more frenetic days of fall.

7.    Football season. With autumn comes thoughts of the Big House. An excellent season is forecast. This is relevant to us at Michigan Urology for a number of good reasons. First, Wolverine Football is a central feature of the fall environment in Ann Arbor. It brings pride to our community, our students, our faculty, and our alumni. Pride in one part of our university extends to all parts – each unit wants to be equally successful in its own game. Football is a feature of our alumni reunions (the Nesbit Reunion in particular). For some reason a successful football season seems to boost applications to most of our schools and colleges (I’m not a sociologist, so I offer no explanation). Sports educate us. We see how a genuine sense of “The team, the team, the team” (Bo Schembechler’s enduring quote once again) enhances performance far better than any drug or phony slogan.

8.    

Urology recruiting.  Last month Gary Faerber (Associate Chair, Education), Khaled Hafez (Residency Program Director), Kathy Cooney (HemOnc Division Head and Urology Joint Faculty) and I spent a morning with Brady Hoke (UM Football Coach), Jeff Hecklinski (Wide Receivers Coach and Recruiting Coordinator), and Chris Singletary (Director of Player Personnel) to learn about their amazing work as our own residency recruiting season is about to heat up. Coach Hoke has built up a superb team with a very sophisticated recruiting system and a genuine approach to team development. They gave us nearly an entire morning of play-by-play instructions leaving us energized for our next campaign to recruit our Urology Class of 2019. Michigan Urology will be 100 years old then by the time this next class graduates, by my reckoning (looking at the arrival of Hugh Cabot in 1919), and Michigan Football will be 140 years old then, looking at 1879 as the start of Wolverines Football competition. Michigan joined the Big Ten at its inception when it was known as the Western Conference in 1896. The Wolverines have had the most all-time wins and the highest winning percentage in college football history. Michigan Football coaches have been Fielding Yost, Harry Kipke, Fritz Crisler, Bennie Oosterbann, Pete Elliott, Bo Schembechler, Gary Moeller, Lloyd Carr, Rich Rodriguez, and now Brady Hoke.

9.    Coach Hoke is very big on the study and celebration of history, something that may have slipped a bit in the preceding coaching regime. Schembechler Hall, now in the midst of serious renovation, is a living testimony to the rich and inspiring tradition of Michigan Football. Of course I can’t mention Coach Bump Elliott without recalling his brother Pete, another great Big Ten football coach and the father of my good friend Bruce Elliott, a local attorney and premier girl’s field hockey coach. Both Bump and Pete were great UM athletes. Pete was an All-American quarterback on the undefeated 1948 Michigan football team that won a national championship. He is the only Michigan athlete in history to have earned 12 letters in varsity sports (football, basketball, and golf). After his own great coaching career, he served as the Executive Director of the Football Hall of Fame, in Canton, Ohio, where he died earlier this year at age 86. (Picture with brother Bump Elliott on the right). Pete was not just an extraordinary athlete, coach, and teacher, but he was simultaneously a true gentleman in the highest sense of the word.

10.    Last month Dean Woolliscroft held a ceremony for Bill Smith who stepped down as chair of Biological Chemistry. It seems like yesterday since Bill returned to Ann Arbor as chair, hired then by Dean Lichter. Bill has been a great chair and happily will be remaining on the faculty to do his work as professor, which he does so well. One of the things he said in his remarks that struck me in this day of clinical trials, health services research, and disease-focused research programs was: “Let’s not forsake curiosity-driven science.” An astute comment from another true gentleman.  David Engelke is Bill’s worthy successor as chair.

11. In one of the tensest times of the Cold War, thirty years ago, around this time (actually Sept 1, 1983), military pilots of the Soviet Union shot down a commercial Korean Air Flight KAL-007 on the way to Seoul, Korea. The USSR stated that the pilots did not recognize KAL-007 was a civilian aircraft when it apparently violated Soviet airspace. Of course, conspiracy theorists have proposed alternative explanations, although I’ve come to realize that as a human endeavor military incompetence is more likely than competent conspiracy.

12.   On that flight was US Congressman Lawrence McDonald. Former President Richard Nixon was supposed to have been on that flight as well, assigned a seat next to McDonald, but must have decided near the last moment not to attend the 30-year anniversary ceremonies of the U.S. – Korea Mutual Defense Treaty. Senator Jesse Helms of North Carolina, Senator Steven Symms of Idaho, and Representative Carroll J. Hubbard, Jr. of Kentucky were aboard sister flight KAL 015, which flew 15 minutes behind KAL 007.  McDonald was an ardent anticommunist and one conspiracy theory had it that the flight was shot down to kill this vocal senator.

13.   McDonald was born and raised in Atlanta. His father Harold McDonald, Sr. was a prominent urologist. Larry studied history at Davidson College, medicine at Emory (MD 1957) and had a year or two of surgery at Grady Memorial Hospital followed by two years in the Navy. As a flight surgeon stationed in Iceland he met and married an Icelandic national. While in Iceland he developed a keen concern about communism that would define much of the rest of his life. He came to Michigan to train under Reed Nesbit in Urology, following his older brother Harold McDonald, Jr. Their father, a friend of Reed Nesbit, undoubtedly encouraged the Ann Arbor training due to his regard for Nesbit and the reputation of the program.

14.     Larry’s anxiety over the influence of communism had led him to join the John Birch Society and he became a leader of the organization in SE Michigan. Fellow residents recall that hospital rounds often became “political rounds” and McDonald was known to attend political night meetings throughout the region, sometimes returning home in the early morning hours just in time to get to the operating room. He finished residency in 1966 and returned to Atlanta to practice in the McDonald Clinic. He is recalled as having been a strong advocate of the compound laetrile as an anti-cancer agent. McDonald’s passionate preoccupation with politics was said to be a factor in divorce from his wife. He made one unsuccessful run for Congress in 1972 before being elected in 1974. In 1975, he married Kathryn Jackson, whom he met while giving a speech in California. In 1974, McDonald ran for Congress against incumbent John W. Davis in the Democratic primary as a conservative who was opposed to mandatory federal school integration programs. McDonald won the primary in a surprise upset and was elected in November 1974 to the 94th United States Congress. Interesting how things change – he was an ardent Democrat.

15.   Harold McDonald, Larry’s older brother, finished training under Nesbit in 1963. Roy Correa (Nesbit ’65) recalls Harold as a “type A extrovert” as well as a clinical innovator and excellent bridge player. Harold incurred Nesbit’s wrath when he fell behind 250 operative report dictations, but must have completed that work well enough to regain the good graces of “the Boss” and obtain an academic job at New York Down State Medical Center in Brooklyn as an assistant professor. Ultimately, he returned to Atlanta to practice with his father and brother at the McDonald Clinic. He died of a stroke while playing golf in California. Thanks to Roy Correa, Betty Konnak, and David Skeel for help putting together these recollections. I noted there is a Wikipedia page for Larry McDonald, but not for Reed Nesbit. This needs to be corrected!  Volunteers?

16.   Roy Correa offered me some more interesting Michigan Urology history during our communications about the McDonalds.  “Not sure if you got my first reply relating to Larry and Harold McDonald. I am at our vacation house and writing on an old computer… The thing I left out was the air crash that killed John Wear [the Chicago crash – American Airlines flight 191 May 25, 1979].  John was a resident three years ahead of me along with Bruce Stewart and Barry Breakey. They were a great trio (Nesbit class of ’61).  John was the son of the Urology department chairman at the University of Wisconsin.  His death was a real tragedy as was Bruce’s premature death to prostate cancer; don’t tell me that we should not screen for CAP, probably the best pair of urologists in the country died from it (Stewart / Straffon – ‘59).

17.    Strange that major airline catastrophes (statistical rarities) took the lives of 2 Michigan Urology graduates in such a short interval of time. The 1979 Chicago accident was due to several factors. First, the number one engine separated from the plane shortly after takeoff because a pylon attachment (that held the engine to the wing) had been damaged earlier due to faulty maintenance. Apparently American Airlines, Continental Airlines, and United Airlines had begun to use a maintenance procedure that saved 200 man-hours per aircraft and furthermore (from a positive safety point of view) reduced the number of disconnects of hydraulics, fuel lines, electrical systems etc. from 72 to 27.  This was lean thinking ahead of its time.  The new procedure, however, was difficult to execute and involved stress on the pylon during its support by a forklift during detachment from the wing.  So sometimes “lean” for its own sake may miss a critical piece of context that ultimately voids the value of the “lean change.”

18.   Even so, the aircraft (DC-10) was designed to withstand the loss of an engine and Flight 191 should have been able to return to the air field on its two remaining engines. Wikipedia tells us that “Unlike other aircraft designs, however, the DC-10 did not include a separate mechanism to lock the extended leading edge slats in place, relying instead solely on the hydraulic pressure within the system. In response to the accident, slat relief valves were mandated to prevent slat retraction in case of hydraulic line damage. Wind tunnel and flight simulator tests were conducted to help to understand the trajectory of flight 191 after the engine detached and the left wing slats retracted. Those tests established that the damage to the wing’s leading edge and retraction of the slats increased the stall speed of the left wing from 124 knots to 159 knots. The DC-10 incorporates two warning devices which might have alerted the pilots to the impending stall: the slat disagreement warning light, which should have illuminated after the uncommanded retraction of the slats, and the stick shaker on the captain’s control column, which activates close to the stall speed.”  (The stick shaker has come into recent attention due to the failed landing in San Francisco this summer.) In the Chicago tragedy (AA Flight 191) of 1979, however, both of these warning devices were powered by an electric generator driven by the number one engine. Accordingly, both systems became inoperative after the loss of that engine.

19.   Belts and suspenders.  The first officer’s control column was not equipped with a stick shaker at the time of the Chicago crash, although that alone probably would not have made a difference then as stick shakers were powered from that number one engine. (The stick shaker device was offered by McDonnell Douglas as an option for the first officer, but American Airlines chose not to have it installed on its DC-10 fleet. Stick shakers for both pilots have since became mandatory in response to this accident.)  With these issues we see an essential interplay between industry and regulation. The proportional balance is a matter of constant arbitrage. On one hand in the airline industry the dual stick shaker mandate is probably a public good, with little downside, yet on the other hand in health care the EHR legislation and ironic “meaningful use” constraints (perhaps well-intended) have been premature (the law implementation preceded mature EHR products) and have increased costs and decreased safety from my perspective so far.

20.    The physician is custodian to the human condition.  No checklist, set of duty hours, electronic medical record, or set of regulations or systems can alleviate that prime professional responsibility.

21.  Upcoming Visiting Professorships:

a.) James E. Montie Visiting Professorship: Friday, September 20 from 3:30-5:30 pm, CVC Danto Auditorium.  This year’s Visiting Professor is W. Marston Linehan, MD, Chief of Urologic Oncology Surgery and the Urologic Oncology Branch at the National Cancer Institute in Bethesda, Maryland.

b.) Reed M. Nesbit Urologic Society & Visiting Professor Meeting: Thursday, October 17 – Saturday, October 19, 2013.  Attached is a copy of the meeting schedule.  A great program has been planned and this year’s Visiting Professor is Raymond Costabile, MD, Senior Associate Dean for Clinical Strategy, Jay Y. Gillenwater Professor of Urology and Vice Chairman at the University of Virginia. We are hoping to see many alumni at this event in which we will be recognizing those who completed their training in 2003, 1993, 1983, etc.  For more information and to register contact Sandra Heskett by phone at 734-232-4943 or by email at sheskett@umich.edu.

22.   Last month our internal weekly “What’s New” profiled Julian Wan (Reed Nesbit Professor of Urology, Pediatric Urology Division), Stuart Wolf (David A. Bloom Professor of Urology, Associate Chair for Surgical Urologic Services, Chief, Endourology Division), John Hollingsworth (Assistant Professor, Endourology Division and Health Services Research) and an update from two new joint faculty members Jonathan Dillman (Assistant Professor, Radiology and Urology) and Hal Morgenstern (Professor, Epidemiology, Environmental Health Sciences, and Urology). Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.

Best wishes, and thanks for spending time on “What’s New” this weekend.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu

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/

1.

National holidays are treasured interruptions of the work cycle and the Fourth of July is a favorite of mine. Granted that the fireworks, lawn mower accidents, trampoline injuries, and water sports traumas put an extra burden on our emergency departments and personnel on call, I still enjoy the long weekend and chance to think about the luck of our national circumstance. I’m neither a political scientist nor professor of law, but even pediatric urologists can have (should have) political opinions and appreciations.

2. When the status quo of colonial America was disrupted by a critical mass of disaffected individuals, that diverse and feisty group somehow came together around a set of principles and rules that was larger than their individual selfish interests, yet still served those interests, for the most part. Those principles and rules have held up well for 237 years, requiring tweaking by only 27 amendments (the first 10 comprise the “Bill of Rights”) from 1791 through 1992 and one terrible civil war to correct a grievous error of political compromise in the writing of the Constitution, namely the acceptance of slavery. The resulting rules and principles, along with the public acceptance of them, are largely the reasons we don’t behave as a nation like Syria, Argentina, North Korea, or many other nations you might name (not that we are perfect as a nation). So, happy Fourth of July to all of us. (Painting by Archibald MacNeal Willard c. 1875. “The Spirit of ’76. Location: Abbott Hall, Marblehead, MA)

3. What will the future hold for us and other nations? Can we go for another 237 years? This matter of contingency and possibility depends on far more things than I can understand, but whatever plays out will follow a Darwinian path that some might call survival of the fittest.  This, of course, requires military fitness, but that by itself alone works only in the short run as demonstrated in ancient Egypt, Rome, the lands of Genghis Khan, the Spanish Armada, the Third Reich, etc. A national military needs to be balanced by a civilian representative government to best serve its citizens and stakeholders, including its neighbors. Citizens must have education and opportunity within a stable and fair environment. Somehow, we have managed to get this fairly right in the United States, and we hope the model is gaining worldwide traction.

4. Darwin is credited with understanding how a multitude of tiny variations tweak the descendants of a species over time so that some descendants better fit a future environment that is prospectively unknown. Conventional wisdom is that these tweaks are genetic mistakes.  In reality, however, they are hardly mistakes but intentional programmatic gambles on the future. Nature tries to provide a diversified portfolio of options for each tomorrow. The source of that intent is our greatest mystery. Scientific inquiry, mankind’s useful tool for comprehending the world, has proven the opinion of James Ussher in 1650, namely that the world most likely began in 4004 BC, was somewhat off target.  Everyone is entitled to his or her opinions and we have to credit Ussher for trying to be as precise as he could using the best evidence he had available. Better evidence today tells us that the known universe dates back to some sort of big bang 13.792 billion years ago. Since then the world on any given day has been a matter of contingency and possibility, driven by and resulting in neverending change.

5. Contingency, a noun, is a rather ephemeral (transitory) concept. Like happiness it describes a state of being, but the particular state depends on other things happening or having happened. A contingency may be an event that is neither certain to occur, nor certain to not occur. It depends on some thing. Possibility is an essential part of human happiness. More fundamentally, it is the reason the world exists, starting with some fundamental energy that led to space, time, and matter. For us, in our narrow playground of human interest, the possibilities that human imagination has created are what allows us to control parts of the world and procure better futures for ourselves and our children. Humans turn imagination into reality. That imagination may be small and immediate, or it can be grand and play out over years or generations. We talked about how imagination extends reality two months back in the discussion of Claude Shannon. Dreams and fiction can quickly transform into truth. Look at what a century of science, technology, ingenuity, industry, and government did to the fantasies of Jules Verne.

6. I’ve strayed far from my field and department, so forgive this riff on the Fourth. We are now entering a new fiscal year, approaching a new academic year, and are stepping into a new era of health care in the USA. The world of academic medicine is contingent on the expansive and expensive new possibilities of health care, the changing world economy, and the emerging realities of recent governmental legislation. The world in which our trainees will practice is rapidly taking shape and it will be quite different from that we have known.

7. Our new PGY1s are in action and our new chief residents are on the home stretch, finalizing their plans for next year.  The training cycle for our immediate residents is 5-6 years, but many (last year all of them) take additional training in terms of fellowships to prepare for the contingencies of tomorrow’s urology. It’s interesting to me that we are producing only a few more finished urologists per year in this country as were produced when I completed my training. Many people today argue that we should be producing many more, considering the evolving demographics of the world. Yet, in my years of evaluating electronic billing records for the ABU certification and recertification candidates, I found this country seems to have plenty of urologic manpower for the actual urological surgical “work” in terms of operative cases that require a well-trained urologist. What keeps our 14,000 or so practicing urologists in the USA busy and compensated is largely the office work and small cases that fill their days. So thus we seem to have a conflict between the needs of the public, the free market, and the needs of a profession.

8. 

Cicada mania is sweeping the East Coast with Brood II of the 17-year swarm popping up. It is a great curiosity of biology and example of contingency and possibility that some species have 17-year cycles and others have 13-year cycles.  For some Darwinian reasons the eggs they lay and grubs they become stay underground for these cycles and then appear in such abundance that they overwhelm the unprepared predators for enough cicadas to mate and deposit enough eggs sufficient to keep their game going. I remember the last major Michigan cicada brood swarm in 2004. The tree in our back yard, where I photographed this fellow back then, is gone since we had to chop it down when our deck was replaced. It seemed useful to turn the tree into logs that kept our home warmer for a few winters, although that process moved carbon from our back yard to your atmosphere. The yard was a noisy place in the summer of 2004 and those strange creatures with red eyes were all over the place. That Michigan cicada cohort, Brood X, will be back in 2021.

9. Michigan Urology was different back in our last cicada year. We were smaller, having grown from a little division of the Surgery Department just a few years earlier when we gained departmental status under Jim Montie in 2001. When the brood hatches next it will occur in 2021 – the world will be even more greatly changed. By then the Accountable Care Organization model may be gone and MiChart may be recalled as an awkward federally mediated experiment of the past. I bet a few oddballs like me will still be using 3×5 cards and some sort of pencil or ink to keep track of their patients in addition to the next generation electronic health record (EHR) that possibly may be wonderful and intuitive allowing deep archiving, prompt communication at a national level, and full storytelling in a limited number of optical fields.  Electricity, however, will be more expensive and likely less reliable.

10. Is Moore really less? Moore’s law is the observation that, over the course of computing hardware history, the number of transistors on integrated circuits doubles every two years. Derivative from that is the idea that computing systems get equivalently smaller and cheaper in that interval. However, the smaller and cheaper idea may work at the end user level, but the large data bank farms with their requisite temperature control systems seem to more than offset the elegant capacity, tiny size, and minimal energy needs of your smartphone.  By 2030 Planet Earth will have enormous energy hunger and we will be close to tapping out known oil and gas reserves, plus we will probably have “fracked” everything frackable.

11. Part of my gripe with the expensive, primitive, and encumbering electronic record system we were forced to buy and implement (for quarter of a billion dollars here at UM) is that it is not easy to find the story of a patient. Many visual screens disperse the parts of the story so no single optical field is likely to capture the key elements to understand it quickly. The “filtering” systems can create individual idiosyncratic overviews, but no useful generalization has been found for the 2000 practitioners at UM. It is largely left to each of the 2000 to figure it out themselves. I have found the company unhelpful with my implementation. The expensive and plentiful subcontractors we employed a year ago were clueless regarding the needs of our clinicians’ workflows. To add insult to injury we found that the system we purchased couldn’t “talk to” the same company’s system in Kalamazoo, where some members of our department also see patients (“that would require a special upgrade” – but wasn’t such broad inter hospital communication one of the main points of the federal EHR regulation?). Many of us wondered how it could be that very obvious and basic problems we encountered in our EHR implementation that affected daily workflow, patient convenience, and physician efficiency were not experienced by other health systems that purchased the same system. Obviously they were, but any learning that must have occurred was not translated to us in Ann Arbor. We were told that such things were “proprietary.” Anyway, time to stop griping, today’s EHR is what it is. Our workflow, at least mine and much of what I see in our department and others, is noticeably slower, more painful, and more distant from the actual patient.

12. I recently got a new car. A Ford product from Joe Sesi. The cost was pretty much the same as the cost per physician of the mandated EHR. However, my car is not just an amazing manufactured product that also contains a huge amount of software and complex, yet interactive, electronic systems. Customer service, from Darin Ballenger the salesman, Joe Sesi the dealer, and Ford nationally (by direct phone line to a person) is terrific and ongoing. Anything I need help with in terms of the car mechanically, its software, or my understanding of its operation is readily available from any or all three of those resources from the source. Ford gets it.

13. Workflow is important in health care. If it is efficient, lean, and value-stream oriented it is most likely to give satisfaction to all stakeholders and less prone to error.  As human beings imperfection is part of our reality – to deny this is to step away from reality. Yet, as good and conscientious health care providers (or citizens, for that matter), we want to minimize errors, especially grievous ones.

14. It is a naïve supposition to assume that any electronic medical record can or should capture all of the myriad facets and transactions in the work flow of health care. An interesting paper in the Journal of the American College of Surgeons (“30-day outcomes support surgical safety checklists” by Bliss, Ross-Richardson, Sanzari et al JACS 215:766, 2012) illustrates this point. The authors arranged for surgical cases to be monitored for “safety-compromising events.” In 73 surgical cases they observed 511 such events. My point is that those 73 cases must have also included literally thousands of other “events”, transactions, or interactions that went well. Many interactions between patient and someone in the health care system are routine and some are very complex. However, it is the nature of health care that even routine transactions such as moving or positioning a patient, afford opportunities for error or damage. No system, EHR, or checklist can shelter a physician from the ultimate professional responsibility and perpetual anxiety to “first do no harm.” I fear, however, that a generation of commoditized health care providers will come to believe they are so sheltered from that personal responsibility if they follow guidelines, observe checklists, and dutifully type in their parts of the EHR.

15. We once criticized physicians (often ourselves) who got so wrapped up in numbers and systems that they began to mistake lab tests or pathologies for actual patients. Thus a resident in clinic might go from “a small renal mass” in one room, to a “high PSA” in another, and then take a consult for a case of “unexplained hematuria.” This could be called a matter of statistical physiognomy in which clinical data replaces the “face of a patient.” Today’s new iteration of this error is the substitution of the computer screen for the actual patient, an error we might call “LED physiognomy” or the “meaningful use avatar.” I believe Michigan Urology residents, faculty, and Nesbit alumni graduates will not fall easily into that trap. What distinguished Cabot, Nesbit, Lapides, and our faculty and trainees who followed, was their ability to see beyond the limitations of their colleagues, economics, and systems of their times so as to deliver innovative urologic care, thoroughly integrated with education and scholarship. Statistical and LED physiognomies are the false deities of our era. They may be alluring traps for some medical geeks, but they are certainly bogus.

16. 

Our graduating chief residents Ray Tan, Jon Ellison, George Schade, and Gareth Warren with Lora Allen who was recognized by the residents for doing a great job as residency coordinator.

As I looked at our graduating class of 4 residents and 1 fellow during the dinner we held for them at the Michigan Union last month I saw the best of the best of the next generation of urologists, who will lead the way in our field with the tri-part mission implicit in our art and science. That is to a.) care for patients kindly, well, and innovatively; b.) integrate education thoroughly throughout that care, thus training the next generation of physicians; and c.) expanding the conceptual basis of our field including the systems of health care delivery. Michigan did it well for this class just as has been the case for a long line of classes back to 1926.

17. Michigan Men’s Football is one of our key funding vehicles for prostate cancer research. This idea derived from Jim Montie and Dave Brandon and is dependent on the generosity and enthusiasm of the football coaching staff and our participants.  We had a terrific two days in June with 58 participants and some 21 coaching staff. We will have room for twice as many participants next year and hope many of our readers will either participate or generously send someone out on the turf.

18. 

The McGuire Professorship was inaugurated in June and Gary Faerber was installed as its first recipient. Pictured above from the ceremony are Brian and Mary Campbell with Gary.  Brian and Mary among a number of other friends, faculty, and Nesbit alumni helped fund this professorship.  Gary was trained by Ed, had been our Residency Program Director for 10 years, and is Associate Chair for Education. He is a “urologist’s urologist” and is always among the first to take on another patient in need and add to his clinic or OR schedule without so much as a grumble. Ed McGuire’s mark on Michigan Urology is indelible. He was a perfect and most worthy successor to Jack Lapides and impacted a generation of residents and fellows, thousands of patients, and the basics of urologic knowledge.  Ed retired last month and is now an Active Emeritus Professor.  Ed has held the Reed Nesbit Professorship and we will ask the Regents if it may go to Julian Wan, one of Ed’s early residents, and much like Ed and Gary, a versatile “stand-up” urologist, an innovative thinker, and an essential citizen of our department.

19. Last month we wrote about the importance of medical journals insofar as they take new ideas, vet them through the process of peer review, and publish them for inspection. The peer review part requires thoughtful and generous peers to review submissions, and in this respect some of our faculty really excel. Bill Steers, the Editor of the Journal of Urology, recently sent me a note telling me that 5 of our faculty were among the handful of reviewers honored this year by the “Best Reviewer” Award. I am in awe of these five, who accept and review, with clarity and promptness, a large number of manuscripts each year. My hat is off to Quentin Clemens, John Hollingsworth, Kate Kraft, David Miller, and Julian Wan.

20. Last month our internal weekly “What’s New” profiled Khaled Hafez in the Division of Endourology, Corey Longley the development officer for urology, and an update on the Neurourology and Pelvic Reconstructive Surgery Division directed by Quentin Clemens. Website: http://www.med.umich.edu/urology/about/MonthlyNewsletter.html.

21. This will be our seventh year for the Chang Lecture on Art and Medicine in which we honor the extraordinary Chang family who link Chinese art and Michigan Urology.  Dr. Richard Prager, Professor of Cardiac Surgery and Head of the Section of Adult Cardiac Surgery at the U of M, will present “Art as an Expression of the Human Condition” on Thursday, July 18 at 5:00 PM in the Ford Auditorium of the University Hospital.  We hope to see many of you there and a reception will follow. Friday, July 19 is the Duckett/Lapides Lectureships from 9:00 AM-12:30 PM in the MCHC Auditorium. The visiting professors are Dr. Thomas Kolon, Associate Professor of Urology in Surgery from the Children’s Hospital of Philadelphia (Duckett) on “Cryptorchidism and Germ Cell Preservation” and Dr. Wayland Hsiao, Assistant Professor of Urology at Emory University School of Medicine (Lapides) on “After childhood fertility preservation, what are the state-of-the-art options.”

22. While the faculty and residents are at the lectureship the staff will have their annual training and education day from 8:00 AM to Noon at the BSRB. We welcome back Brian Blasko, a highly motivated, nationally known speaker and trainer, who will present The Car Key Factor in Creating Your Comfort Zone With Communication.  The afternoon is free to enjoy the Art Fair as our annual “birthday” present to our staff (recognizing that a few will have to stay behind to cover phones and emergencies).

Best wishes, have a wonderful 4^th of July holiday, and thanks for spending time on What’s New this week.

David A. Bloom, M.D.

The Jack Lapides Professor and Chair

Department of Urology

TEL: 734-232-4943

Email: dabloom@umich.edu