Matula Thoughts October 3, 2014

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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 September 5, 2014

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Matula Thoughts September 5, 2014

Michigan Urology Family

Seasons, health care goals, required reading, truth & proverbs.

 

Rose

  1. The writer Gertrude Stein once said: “A rose is a rose is a rose.” This summer has been replete with many roses but, with all due respect to Stein, if you look closely enough none is exactly the same as another. An equivalent generalization might be: “A year is a year is a year.” Although we begin the Earth calendar year of 12 months and 365 plus days on January 1 we also begin it at other times for specific purposes. Our fiscal year as well as the residency-training year start on July 1. The medical school students’ first year began just last month on August 3 with the White Coat Ceremony on a Sunday afternoon in Hill Auditorium. In the presence of their families and friends each student crossed the stage, announced his or her name, and received a short white coat and a stethoscope. We have been organizing the stethoscope presentations for the past ten years as a gift from the clinical departments and several benefactors in our community to the tune of more than $250,000 over the decade. Just as the stethoscope is a symbol for the practice of medicine, their presentation to the incoming medical students is a symbol of commitment of the clinical teachers and community to the education of the next generation of physicians. As the new students settle into their routines yet another type of year, the university academic year, began a few days ago on September 1 and with it now underway we find Quentin Clemens, Khaled Hafez, Brent Hollenbeck, and John Park promoted to professor and Jeff Montgomery to associate professor. These men are the best of the best in their areas of practice and scholarship. We welcome two new colleagues to our faculty: Jim Dupree who completed a Male Reproductive Medicine and Surgery Fellowship at Baylor College of Medicine and Nick Warner who finished a Trauma Reconstructive Fellowship at the Detroit Medical Center.

Koz White Coat

[White Coat Ceremony Hill Auditorium August 3, 2014. The cloaking of first year medical student Andrew Kozminski by his father Mike (Nesbit 1989) and brothers Michael (PGY 5) and David (UMMS class of 2016).]

 

  1. The White Coat Ceremony marks the starting point for a life of medical education. Medical school graduation, usually four years later, is a major milestone along the pathway of lifelong learning that necessarily follows. Completion of residency training and its fellowship extensions are other occasions for celebration, these periods typically exceeding the four years of medical school. Specialty board certification a few years after formal training ends is an essential checkpoint for independent practice of urology, but now we find the concepts of “lifelong certification” and “re-certification” have turned into systematic “maintenance of certification.” You might question the point of all this – what are the goals of medical education, residency training, and certification in the first place? The answer to these questions requires historical framing and a belief in the balance of public policy and the right of a profession to set its own standards. Ultimately, however, they beg larger questions: what are the goals of healthcare and how do we best accomplish them? We touched on these issues briefly last month, considering healthcare metaphorically as necessary “attendence at the service stations of life”, to use Horace Davenport’s metaphor. The questions just raised are deep and essential – not just for those of us engaged in the processes of medical education, healthcare, and research. These issues are central to our work and lives, and they compel much of the attention of this communication we call “Matula Thoughts.” As a basis for further considerations I’d like to call your attention to a new book by Danielle Allen, called Our Declaration. This should be required reading for everyone. It is a deep, but very smooth dive into the 1337 words of the Declaration of Independence. Professor Allen will give you a new understanding of the ideas of liberty and equality relating directly to our immediate daily concerns of health care, professional standards, and public policy. The book came out right around Independence Day and I only just recently finished it, but will be coming back to it again in future “Matula Thoughts.”

 

  1. Ed Tank (Nesbit 1971) is a great role model for me with the idea of keeping a book, a real book, on your person when travelling about so you can always have something to read worthy of your time. I recall him in years past carrying around substantial hard-bound volumes to read at spare moments. My wife Martha, on the other hand, carries an iPad with its library of books weighing only a couple of ounces, but my preference is for slim paperbacks or little hard cover books that fit into a sport coat pocket. Coming back from the AUA in Orlando, with a side trip to Memphis, I carried Tolstoy’s The Death of Ivan Ilych. This little paperback is part of a series called The Art of the Novella by Melville House. The book, with its new translation by Ian Dreiblatt, caught my eye at our new bookstore, Literati, in downtown Ann Arbor so I picked it up and took it along on a few previous trips, until its time to be read came up on that journey.                                         Tanks & King copy  [Ed  & Rosalie Tank, with the late Lowell King on right]

Literati  [Literati Bookstore, Ann Arbor]

 

  1. The story is simple. Ivan Ilych, a fictional 45-year old successful Russian attorney died in St. Petersburg on February 4, 1882. Discovering that fact in the newspaper the next day at work, his colleagues commented on Ivan’s demise with varying degrees of sympathy. Tolstoy then recounts the life of the man, gradually revealing ironies of Ivan Ilych’s career, marriage, and friendships, all viewed at first impression as conventionally successful. The illness that caused his death dated to an injury sustained two years earlier when Ivan Ilych struck his side as he fell off a ladder. He had been trying, at the moment, “to show the uncomprehending upholsterer how he wanted the drapes hung” in his stylish new home. Dull discomfort in the left flank gradually increased after the injury, leading to pain. Consulting physicians offered varying opinions and “a urine test” was mentioned, although Tolstoy gave no results. Malaise, cachexia, and intolerable pain ensued over the next two years. Finally Ivan Ilych became confined to his couch for weeks until his end came. Whether intended or not, this story is an accurate and brutal depiction of death from an untreated kidney cancer that had likely ruptured.

 

  1. Tolstoy (1828-1910) was either anatomically confused or mischievous in explaining how the physicians considered Ivan Ilych’s illness a matter of the appendix or kidney, even though the left side was clearly specified. The term “floating kidney” was added to the diagnostic mix. We must take into account the state of medical knowledge and urology in particular during the later years of Tolstoy’s life. Emotionally, however, Tolstoy had perfect pitch. His portrayal of physical deterioration, the anguish of impeding death, as well as the complex and often insincere responses of family and friends, was terribly convincing. The gradual unraveling of Ivan Ilych’s pretension, self-delusion, and dignity embittered his final days as he recoiled from attempted acts of kindness. Ivan Ilych offered a number of Joycean internal riffs, but produced no grand Shakespearean soliloquies although he surely came to question who he was, indeed he wondered “what he did wrong” to incur his horrible fate. He tortured himself in the final weeks searching his memories to comprehend how the life that he had believed so sweet could turn into an irreversible nightmare, until he suddenly realized: “There is no explanation!” His story, though, is an exaggerated version of everyone’s story. Who we are, to ourselves and to those around us, is a story of many versions. From Ivan Ilych we see that even who we think we are is, to some degree, a self-delusion.

 

  1. Tolstoy targeted our imagined personal exceptionality While acknowledging that we know all men are mortal and that each of us is a member of mankind sharing the same fate, we nonetheless individually carry the delusion through most of our lives that the mortality proposition doesn’t quite include “me.” Our personal exceptionality is both true and not true. While we each are unique and indelible to ourselves, none of us is uniquely exempt from that ultimate prescription of mortality. The same holds true for Stein’s rose. How Tolstoy came to the beliefs he had in 1886, at age 58 when he wrote the story of Ivan Ilych, can perhaps be discovered though his semi-autobiographical fiction and the serious biographical work that has accumulated. Interestingly, if you go to the web site worldcat.org/identities/Iccn-n79-68416/ you find a publication time line that shows the yearly volume of publications by Tolstoy and about Tolstoy. Notably, the two categories are approaching parity, indicating that people today read almost as much about him as by him. For a student described by his teachers as “both unable and unwilling to learn” Tolstoy turned out pretty well as a mature literary figure, although using our modern vocabulary of political correctness he would be branded as “disruptive.” This adjective is widely overused today in its negative connotation, even though we recognize value to “disruption” in the scientific, technological, and business worlds. Politically and culturally, Tolstoy’s disruptions improved mankind and his reach is still growing. If you re-read Ivan Ilych that reach will grow a little more, and so might you. Were Tolstoy still alive, he would have celebrated his 186th birthday last week.

Tolstoy[Tolstoy, disruptive author]

Tolstoy pubs[worldcat.org/identities/Iccn-n79-68416/]

  1. The chances for a patient with kidney cancer have improved vastly since the fictional death of Ivan Ilych. One hundred years later by the time of my residency and early years of practice, the miracles of diagnostic imaging, anesthesia, plus efficacious operative techniques in the hands of well-trained surgeons the outlook for patients with kidney cancer had improved markedly, yet another quantum leap was soon to follow. As junior staff person at Walter Reed Army Medical Center in the early 1980s I met another young urologist, Marston Linehan, who had just taken the urology position at the National Cancer Institute. In the years since then he has practically written the book on kidney cancer, elucidating the various metabolic pathways that cause it, classifying its genetic types, and discovering targeted treatments. I have several close friends alive and well today due to the combination of Marston’s discoveries and superb surgeons. I recently wrote to Marston about Ivan Ilych and found that he, of course, had read it years ago. The book is short and well worth re-reading even if you too had encountered it years ago. It slips easily into your pocket, or you can go the route of Kindles, smart phones, and iPads if they are your preferred media tools. Marston Linehan, M.D. is still Chief of Urologic Surgery and the Urologic Oncology Branch, Center for Cancer Research, at the National Cancer Institute, National Institutes of Health in Bethesda, Maryland. He and his team identified the critical genes responsible for von Hippel-Lindau Disease, clear cell renal carcinoma, hereditary papillary renal carcinoma, chromophobe renal carcinoma, among others. Marston’s work has led to understanding of the genetic events associated with the initiation and progression of urologic malignancies thereby enabling successful therapeutic strategies. He visited us here in Ann Arbor last autumn.

Linehan 07[Marston Linehan]

 

  1. We conveniently divide writing into fiction and nonfiction. The boundary is important to us as physicians and scientists, because truth is a presumption of our work. Trust underpins everything in medicine and science. When dishonesty, in the form of false reporting, lies, or plagiarism are discovered trust is lost. The adage “trust, but verify” is useful although in the helter skelter of clinical work or the fast-moving world of modern scholarship, every detail cannot be quickly verified. When a colleague tells you that a patient’s creatinine in 1.0, you trust that report and make assumptions and critical decisions based on that “fact.” Honesty is essential, whereas accuracy is an aspirational trait that must be honed. Don Coffey, great role model of critical thinking for many of us, carried the idea of truth a step further when he said: “You need to know the difference between facts and true facts.” Tolerant of human frailty, but evangelical regarding the pursuit of excellence, Don also once said to me “Anybody can make a mistake, but it shouldn’t become ‘a way of life.” The rich vocabulary of integrity indicates its centrality to the human condition. An old proverb says “truth is the daughter of time.” Lincoln said: “No man has a good enough memory to be a successful liar.” Frankfurt, the esteemed philosopher at Princeton, wrote: “Any society that manages to be even minimally functional must have, it seems to me, a robust appreciation of the endlessly protean utility of truth.” Furthermore he said: “It seems even more clear to me that higher levels of civilization must depend even more heavily on a conscientious respect for the importance of honesty and clarity in reporting the facts, and a stubborn concern for accuracy in determining what the facts are.” I have been astonished on rare occasions to find blatant plagiarism in my role as a journal reviewer from people who clearly “should know better.” How I deal publically with these rare birds in academia has been a dilemma. Do I call them out, do I attempt to educate them, or do I remain within the comfortable anonymity of the peer review process? What should be my obligations towards honoring someone else’s dishonesty? On the other hand, when does academic sloppiness slip into convenient plagiarism? I don’t have good answers for these questions.

Coffey 06 copy[Don Coffey, Professor of Urology, Johns Hopkins]

 

  1. Scientists cannot be dismissive of fiction, however, because good fiction is an exercise of human imagination that illuminates a “real world” of facts and true facts. This brings us to the almost paradoxical consideration that there can be truth in fiction, insofar as a story is authentic. The world imagined in a writer’s mind, stripped clean of distracting elements and illuminated with precision, may give a more precise picture of reality than might otherwise be observed in the “real world.” This is the beauty and utility of story-telling. Ivan Ilych serves us well, illustrating the rough natural history of unattended kidney cancer, the definition of a “well-lived” life, and ultimately the individual comprehension and social indignities of death. Yet just as reality can be better understood through fiction, fiction can be double-edged and distort reality. This thought brings us to the uncomfortable question that naturally arises from Ivan Ilych’s story: When does belief in our own narrative stray into fiction? The fictional death of Ivan Ilych is a reasonably authentic depiction not only for a death from uncontrolled renal cell carcinoma, but more so for an end of life in general. In the grand scheme of life, a death is a death is a death. Yet death is usually only a footnote to the unique opportunities and accomplishments of each life, with the roses enjoyed along the way. Our faculty and their teams in the Uro-Oncology division (three of whom were just promoted academically as mentioned earlier) deal with death more than the rest of us in the department, they being more so attendants at the later service stations of life. Yet each of us, at the personal level, will stop at those stations. The most important estate each of us leaves behind, after that last station, aside from family and friends, will ultimately be our work and our integrity. After all, while roses are seasonal and variable, truth is the legitimate daughter of time.

Rose   [Rose garden of Bob and Mary Lichty, Waterloo, Iowa]

 

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

David Bloom

 

 

Matula Thoughts August 1, 2014. Art & medicine.

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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

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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

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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]
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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

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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

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Matula Thoughts April 4, 2014

Michigan Urology Family

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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.

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

Matula Thoughts March 7, 2014

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Matula Thoughts March 7, 2014
Michigan Urology Family
Curiosity, polar thoughts, cats, dogs, & the human element

Amundsen at South Pole

Amundsen at South Pole

Amundsen dressed for polar vortices

Amundsen dressed for polar vortices

  1. The days of winter are counting down now that March is here. It has been a curious season of drastic shifts in weather, highlighted by the Polar Vortex. Last month in “Matula Thoughts” we touched on Norse mythology and today want to include some Norse reality, specifically Roald Amundsen, the polar explorer and man of many firsts. Born as a fourth son in 1872 to a family of ship owners and captains in Borge, in the United Kingdoms of Sweden and Norway, his mother hoped for him to avoid the family business. As a young man he promised her he would become a physician, but after she died when he was 21 he quit his studies and went to sea. He made his mark early and became first mate on the Belgica in the first expedition to winter in Antarctica (winter of 1898-99). He then led the first expedition to traverse Canada’s Northwest Passage (1903-1906). Arriving in Nome in 1906 Amundsen learned that Norway had just become independent of Sweden and he sent the new Norwegian King a patriotic note regarding the expedition’s success. Amundsen’s 1911 Antarctic expedition was the first to reach the South Pole (but lacking satellite phone technology the world didn’t learn of the fact until this very day March 7, 1912). His 1926 Arctic expedition was the first to indisputably reach the North Pole. Earlier claims from others were controversial, but the 16 man-expedition with Amundsen as leader and navigator was the first as their hydrogen-filled semi-rigid airship, the Norge, on May 12, 1926 flew directly over the North Pole. Amundsen disappeared in an Arctic rescue mission in June 1928. One can only marvel at the Norse Human Element and speculate what Amundsen’s curiosity might have elicited had he focused on medicine.
    Nansen the cat

    Nansen the cat

    Nansen the Nobel laureate

    Nansen the Nobel laureate

  2. Curiosity did kill the cat, by the way. Nansen was the name of the ship’s cat on the Belgica in Amundsen’s Antarctic Expedition. The cat, named for Fridjof Nansen, died on June 22, 1898 while the Belgica was wedged in pack ice for nearly a year. The mascot’s namesake, Nansen the human (1861-1930), was a great athlete, biologist, explorer, and Nobel Peace Prize Laureate. As a prominent citizen he was a strong advocate for the independence of Norway. The cat had a lot to live up to. [a. Cat drawing by his owner, cabin boy and assistant zoologist Johan Koren; b. Fridjof Nansen, Nobel laureate.]

    Periodic_table_(polyatomic).svg

    Human Factor

  3. Last month we mentioned some elements listed on the periodic table, including thorium and radium, and now want to continue that theme with bromine and chlorine. Although not radioactive, these halogens are corrosive and toxic (bromine) and strongly oxidizing (chlorine). The fact that elements of the periodic table have somehow assembled throughout the universe to produce such things as H2O, NaCl, larger compounds, creatures like Nansen’s cat and then the human brain is perpetually astonishing. This thought makes me marvel, as well, at the advertising ingenuity of Dow Chemical Company that developed a campaign with the powerful idea of the “human element.”220px-HDow1888
  4. Herbert Dow was born February 26, 1866) in Canada, and after early childhood in Connecticut, he grew up in Cleveland, where he attended the Case School of Applied Science. His interest in chemistry led to the study of underground brines, and his discovery that groundwaters in Canton, Ohio and Midland, Michigan were unusually rich in bromine, an important ingredient in medicines and the merging photography business. A year after graduation he obtained a patent for a process to extract bromine and expanded his electrolysis methods to produce chlorine and other products. In 1897 he founded the Dow Chemical Company in Midland and the company stands today as one of the great global businesses. Dow died in 1930 and his widow Grace in 1936 established the Herbert H. and Grace A. Dow Foundation. You may have seen the Dow diamond logo last month as one of the partners in the Olympic & Paralympic Games.dow-logo
  5. Our Urology Department at the University of Michigan owes a large debt to the Dow name, for it was the Herbert H. and Grace A. Dow Foundation that delivered us from the trailer. By this I mean our fledging Health Services Research (HSR) Division, created by Jim Montie and inaugurated by John Wei started out in a part (709 sq. ft.) of the “temporary” trailer adjacent to our old Women’s Hospital. The trailer still stands, just like the fabled Hewlett-Packard Garage in Palo Alto (that too has relevance to the University of Michigan Medical School).
    Our fabled HSR trailer

    Our fabled HSR trailer

    The Dow Foundation generosity allowed our HSR Division to move into much more favorable space in the Martin Corporation’s Michigan House (4600 sq. ft.). This beautiful endowment propelled our Dow HSR Division into the intellectual stratosphere, educating the leaders and best of the next generation of educators, investigators, and clinicians in urology. Success creates a new set of issues and under the successive leadership of Brent Hollenbeck our Dow HSR Division outgrew even that ample space in the Michigan House, causing recent relocation to more spacious room for growth in Building 16 at our North Campus Research Complex (NCRC).

    Screen Shot 2014-03-04 at 2.45.22 PM

    Jim Montie

    Screen Shot 2014-03-04 at 2.50.20 PM

    John Wei

  6. David Miller now heads our Dow HSR Division, leading a talented team to ask and answer important questions related to how we deliver urological care. What is the “right” treatment for an individual patient? When and where are the optimal times and places for treatments? How should society allocate costs of urologic healthcare? Our patterns of practice must be dissected and rebuilt even as health care practice is changing in front of our eyes. The Dow HSR has stimulated a cadre of superb students, residents, fellows, and faculty who are asking good questions and finding important answers. Their work has attracted serious attention of policy makers, scientists, and care providers.

    Brent Hollenbeck Former HSR Director

    Brent Hollenbeck
    Former HSR DirectorDavid Miller, Current HSR Director

  7. David Miller,
    Current HSR Director

    A number of years ago The Lancet had a curious Editorial entitled “What is the point of surgery?” and that question has stuck in my mind. [The Lancet 376:1025, 2010] I put the article in a folder of “curious thoughts” and the following year added another paper to it: “What patients really want from health care” by Allan Detsky. [JAMA 306:2500, 2011] Detsky considered three levels of priority. The first level listed 9 items that the public wants most: restoring health when ill, timeliness, kindness, hope & certainty, the “three C’s” of continuity/choice/coordination, private room, no out of pocket costs, the best medicine, and finally medications & surgery. The second level priorities were; efficiency, aggregate-level statistics, equity, and to some extent transparency of conflict of interest. The lowest level of priority for patients consisted of two things: real cost and percent gap of GNP devoted to health care. Questions like these may once have seemed rude and pointless to proud ivory towers in academia, but today they are exactly what the public wants to know. Academic medical teams can answer these better than politicians and pundits. While Detsky among others can pose important questions like he did, the best answers and solutions will come from groups such our Dow HSR unit.titina

  8. Italian engineer Umberto Nobile, as a young man became an enthusiast of semi-rigid airships and after a period of work in Akron, Ohio with Goodyear, he returned to Italy to build a new airship. Hearing of this Amundsen developed a collaboration with Nobile to find the North Pole, naming his hydrogen filled airship the Norge. The actual flyover, however, turned into a “circus wagon in the sky” according to Amundsen. Nobile had brought his dog Titina, 12-pound Fox Terrier, aboard as ship’s mascot. Nobile had rescued the starving puppy on a street in Rome only the year before. Amundsen was furious that his Italian partner had brought the dog along since the airship quarters were so cramped. Tensions increased when Amundsen noticed as the American, Italian, and Norwegian flags were dropped on the pole, the Italian flag was noticeably larger than the others. Although the expedition fueled national jealousies, it was the first to actually find the pole. Other expeditions that claimed the pole lacked navigational accuracy, and Admiral Richard Byrd’s alleged “fly-over” in a Fokker F-VII, the Josephine Ford (named for Edsel’s daughter) on May 9, 1926 turned out to be inaccurate, with falsification of navigational journal data. Titina proved to be a worthy companion for the grumpy explorers on the Norge and helped the human element remain moderately human throughout the difficult days of the journey.
  9. It’s difficult to escape the power of Dow’s metaphor of the human element. Companionship, of any kind – even canine or feline – maximizes the human element. Whatever forces (selfishness or selflessness) propel human curiosity to explore, innovate, and discover the net results have served our species in aggregate far more than serving the individuals. Amundsen died at 55 disappearing in the Arctic while flying on a rescue mission. The mission was to recover survivors of the crash on sea ice of the, Italia, another airship of Nobile who was on board with his companion Titina. On May 25, 1928 after a series of mishaps the Italia lost altitude and hit sea ice. The gondola smashed open, dumping supplies, nine personnel including Nobile, and Titina. Relieved of the weight, the airship rose with 6 crew still on board, drifted away and was never seen again. The survivors on the ice radioed for help. Several rescue missions set out to recover the crew over the ensuing weeks, but it was Amundsen’s group on a Latham 47 flying boat that disappeared on June 18. The Italia survivors were spotted by other rescuers on June 20, and saved in turns between June 23 and July 14. Nobile, Titan, and eight other crew members survived. Curiosity obviously has its downsides, and perhaps dogs are more durable than cats in polar explorations, but the future depends on human curiosity and innovation. Those of us in urological practice, science, and health services research have the advantage of extending our curiosity in safer and warmer environments.
  10. What’s next in urology? What’s the next North, South Pole, or Midland brine to be discovered for Uro-Oncology, Pediatric Urology, Neuropelvic Reconstructive Urology, Sexual Reproductive Urology, Health Services Research, or Urology in general?  Michigan Urology has been a key player in pushing back many urologic frontiers since the time Hugh Cabot came to town in 1919 and placed Ann Arbor on the center stage of genitourinary surgical practice, research, and education. While it is inspiring to understand the history of one’s institution, every new generation, each new faculty cohort, each new residency and fellowship class must start anew from the baseline of knowledge and skills they find at entry to the profession. The spirit of exploration can get dampened by the necessities of every day’s work, but every generation has its leaders and best in whom curiosity is not just retained, but even energized by the annoyance of their confinements in their time, geography, and knowledge.

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

David Bloom

Matula Thoughts February 7, 2014

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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

Quixotic Thoughts January 3, 2014

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1. A new January and 2014 are at hand and given general and personal good fortune for you and I, along with the Urology Department, a good year lies ahead in spite of great change swirling around us. The year began with the thrilling Winter Hockey Classic in Michigan Stadium between the Red Wings and Maples Leafs. The same day we saw health care extended to millions of “uninsured” and elimination of the odious pre-existing illness restrictions and life-time limits on benefits. Few can deny these important public goods, but the collateral damage of the legislative and regulatory context of these changes is significant. While we cannot cling to the past, not all that is new turns out for the greater good. Rather than massive shifts in the superstructures of health care, we should recapitulate the Darwinian methodology of creating optimum adaptive phenotypes for the future. That is, we need to create new (experimental) clinical, educational, and research models in the hope that some of these might best fit the immediate but unexpected environments of tomorrow.

2. The 16th century Spanish writer, Miguel de Cervantes Saavedra, said in his book Don Quixote: “To imagine that things in life are always to remain as they are is to indulge in an idle dream.” [Part 2 Chapter LIII] He mischievously added: “It would appear, rather, that everything moves in a circle, that is to say, around and around: spring follows summer, summer the harvest season, harvest autumn, autumn winter, and winter spring; and thus does time continue to turn like a never-ceasing wheel.” Cervantes surely knew that as seasons cycled regularly, even in his retrograde version, no two successive ones were identical.

3. Change was exemplified on this particular day (January 3) in many years past. In 1496 on January 3, for example, Leonardo tested a flying machine, but lacking an aluminum internal combustion engine, the deep mechanical expertise of the Wright brothers, and the winds of the outer banks he didn’t break the barrier of sustained heavier than air flight. Still, he was far ahead of his time and technology. Our national geography changed on this day in 1823 when Stephen Austin received a grant of land in Texas from Mexico and in 1959 when Alaska became the 49th state. And who could have predicted on this day in 1977 when Apple Computers was incorporated that the whimsically-named company would become one of the largest companies in the world (currently #15 by Forbes listing for 2013 and #1 by market capitalization in 2013 Q1 and Q3 – dropping to #2 in the second quarter of the year). We should also keep in mind that 2014 is a full century after the start of the ill-fated War intended to end all wars. Change is inexorable and although not all change is good, we need to not only survive change, but come out better at the end of it.

4. Last month’s story of the Halifax disaster elicited a comment from my friend and colleague David Diamond of Boston Children’s Hospital who noted that every year the City of Halifax sends his Children’s Hospital a splendid Christmas tree in thanks for the outpouring of support and volunteers that rushed to Nova Scotia after the horrendous explosion.

5. With Stu Wolf as Acting Chair of the Urology Department for the first quarter of 2014 we repeat last year’s very successful experiment with John Wei in charge. One of the fruits of my mini-sabbatical labor then was our departmental A3 and its derivative “baby A3s” that have benefited our departmental thinking and operations. John did a superb job in the front office and brought great ideas and analyses to the department, continuing to provide leadership and clear thinking. His quarter at the helm changed him and benefitted our department. Stu will likewise bring valuable new insights and ideas to our departmental table.  John Wei has taken over the weekly production of “What’s New” except for the larger broadcast on the first Friday of the month that Stu will produce as chair. I missed this ritual last year, so I will independently keep up the “Matula Thoughts” Blog. You will thus have two fabulous reading options for that first weekend of each month this winter. If you must choose just one, I recommend picking the “What’s New” of Stuart.

6.   Don Quixote 1605 I started to read Don Quixote a number of years ago out of curiosity and what I felt to be a need to be familiar with key parts of our literary heritage. My sally into the canon didn’t take me to the very end of the story, as the adventures of the deluded knight-errant, while initially amusing, became tedious. In short order the wanderings of the Don, Sancho, and Rocinante became supplanted by Urology Department promotion letters, recruitment, retentions, committees, Faculty Group Practice, patient care, and other day-to-day matters. Accordingly, the book (Modern Library, Samuel Putnam translation, 1998, over 1200 pages) found its way back to my shelves. (Picture: Title page first edition of Don Quixote Part 1, 1605)  Actually titled The Ingenious Gentleman Don Quixote of La Mancha, the text was a foundational work of modern Western literature. Published in two parts by Spanish author Miguel de Cervantes Saavedra in 1605 and 1615, the book tells the story of Alonso Quijano, an older member of the nobility who becomes so brainwashed by chivalric stories (the novels of his era) that he sets out to revive chivalry. The term chivalry comes from the obvious French word meaning “horse soldiery” and carrying with it characteristics of gallantry, training, service, and knightly virtues including courtesy, love, and honor. The Knight’s Code of Chivalry was a moral system requiring knights to protect those who were incapable of protecting themselves. These fundamental values emerged during the earliest human existences of small bands of hunters and gatherers. Over ensuing millennia these values were incorporated for larger society by religions. The Spanish and Portuguese knights’ codes of Cervantes’s era offered laymen’s versions that simultaneously supported the church and translated those values into the special obligations of a “profession.”

7. With the enlightenment it became clear (“self-evident” as said in the founding documents of the USA) to many thinkers and occasional leaders that a moral system with values such as those in the knights’ code was a duty of the state or government. Our Declaration of Independence, Constitution, and Bill of Rights took over from religions, knights, and philosophers. The essential values of life, liberty, the pursuit of happiness, and equality were stated well and eloquently in those documents, although our national execution has been imperfect and the prime fault at the start was the persistence of human slavery that took a civil war and a further century of countless injustices to start to set straight, although it still persists in this world. Social justice is elusive. Health care is intrinsic to any reasonable modern chivalric code. Our dilemma is how to get it right, how to find the right mix of federal, state, professional, and private sector contributions even as rapidly evolving technology heightens the complexity and costs of health care. The private sector of business and the health care professions together cannot fill all of the health care needs of the people of a nation. The government alone is also woefully inadequate. Furthermore an insurance paradigm makes no sense either as the dominant methodology of providing health care to a nation. Hundreds of billions of dollars, complex legislation/regulation, and incalculable political rhetoric are only making matters worse with a good solution further away from today.

8. Cost of Tech - JAMA copy Last October I mentioned an amazing crayon drawing made by a little girl as her sister sat on a doctor’s examining table. In the picture the patient, the mother and little baby on her lap, and the 7-year old artist were regarding the viewer in the best tradition of Vermeer. In contrast, the physician sat off to the left side, intently typing on a keyboard and looking at the computer screen. The accompanying article in JAMA was written by Elizabeth Toll, at Brown University, and the copyright for the illustration listed Dr. Tom Murphy (likely the physician so-depicted).  Both he and Dr. Toll kindly gave me permission to utilize the picture that I’ll show again. [The cost of technology. Toll. JAMA 307:2497-2498, 2012] The illustration shows how the electronic medical record, mandated in swift deployment by the unfortunate HITECH Act, has become for many of us, a surrogate for the patient. Technology has gone beyond enabling to distorting the practice of medicine. This is just one more threat to the idea of medical practice as a profession. Many social and regulatory pressures are forcing the commoditization of medical practice, with a misguided belief that technology will solve the problems. The ridiculous mandated complexity of ICD-10 is another related matter (see the article in New York Times Business Day by Andrew Pollack December 30, 2013” “Who knows the code for injury by Orca?”).

9. Medical practice is just one part of health care and even that part consists of many goods and services. Some parts of health care are best dealt with by society as commodities. For example, perinatal care, immunizations and dental cleaning. These all serve the public interest and can be delivered economically by a number of means. They can be delivered efficiently as public goods at free clinics. They can also be delivered very conveniently at drug stores, grocery stores, or in smartly-designed health care facilities (how I wish we were so “smartly-designed” at the University of Michigan). They can also be provided in professional offices. In an ideal free society, people generally have a choice as where to obtain these commodities, but in any case when people don’t have a reasonable choice the important commodities must somehow be provided.

10. Other professional activities are more complex, such as the sorting out of a specific health problem and finding a remedy. The remedy itself may require a complex orchestration of personnel and a complex performance of the manual (and now robotic) arts of surgery. A professional doctor-patient relationship lies at the heart of most of these amazing feats of modern healthcare. Even more complex, but something modern healthcare has not effectively solved, is the simultaneous management of the many interlocking illnesses we call co-morbidities. These involve numerous health care specialists and specialties, often in multiple separate health care systems, insurance programs, and states. The simplistic idea of a “medical home” cannot be legislated or mandated by regulation. Whether or not a single patient care relationship between healthcare professional and patient can remain at the center of modern health care is a very real question right now. The answer is “to be determined.”  If such a central relationship is replaced, we have to imagine what the world of health care will look like for us (as we ourselves and our families are patients) as well as what it will look like for those we serve on a daily basis.

11. The answer may be in front of us as we look at what health care is like for the many people who lack a primary care physician and get their care at urgent care facilities, from ad hoc specialists, emergency care centers, or forgo care in many instances. Is this a scenario we want to embrace? The choice will not be ours to make, as economic, social, and legislative forces are moving things in that direction. Primary care physicians are becoming harder to find, we know this acutely here at UM, even as new health care legislation forces the centrality of the primary care physician in the evolving superstructures of health care like the accountable care organization. The idea of a primary care person as a gatekeeper and coordinator in our indisputable world of specialty medicine may be outdated. The Norman Rockwell ideal of the GP is a lovely sentiment, but while it represented the world of 1940 in industrialized countries, it no longer fits today where the American Board of Medical Specialties certifies around 150 areas of specific medical practice. Even with my previous involvement with the ABMS I cannot name them all, and even have to think very slowly to come up with most of the names of the 24 primary member boards.

12. Professional activities, such as operative procedures, are becoming framed by guidelines, check lists, time-outs, mandated documentation, and other constraints. These formalities relegate those human performances to isolated “procedures” that neglect the totality of the patient and family.  I can’t really argue against guidelines, checklists, and documentation per se, but I believe that rigid incorporation of these things into “systems” should not replace the professionalism that must underlie the best surgical arenas. In the United Kingdom, these operative performances are described as occurring in the “surgical theatre.” The terminology is apt; great performances do not lend themselves to commoditization. Some readers might challenge these thoughts as quixotic, but I hope they are not. Humans are hard-wired to value excellence, and professionalism has passed the test of Darwinian endurance for at least two and a half millennia as evidenced in the Hippocratic Oath. The doctor –patient relationship underpins the health care that people value most, whether in our Taubman Urology Ambulatory Care Unit or in the landscapes of Africa where Doctors Without Borders tend the marginalized citizens of the world trying to survive wars, genocide, hunger, displacement, and natural disasters. We are not finished with wars and natural disasters, but should be smart enough to avoid them, minimize them, and contend with them better than we have up to now. WWI on a global scale was the result of political stupidity and human arrogance, the Halifax Disaster was a blunder of multiple human errors within the war, but the response to it revealed some of our best human virtues and behaviors.

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

David Bloom