Fair weather, formicidae, fables, and funambulism
August in Ann Arbor with long days of sunlight, warm breezes, and summer clothing is especially sweet by contrast to our winter days. Thanks to generous rains filling our rivers and refreshing the ground water Ann Arbor’s August is immersed in green. [Above: view from the roof of the Brehm Tower of Kellogg Eye Center. Below: kayaks by the Huron]
Birds, cicadas, tree frogs, and lightning bugs create accidental symphonies of sound and light in my neighborhood. Summertime in the Northern Hemisphere brings a measure of balance, relaxation, and sunny public spaces. Vacation allows time to recharge and summer in Ann Arbor is pretty much as good as it gets for doing that.
[Michigan Stadium from Ann Arbor Golf Outing]
August in parts of Europe is almost entirely set aside as vacation time for many workers, whereas in North America “work-life balance” is stricter with a week or two of vacation, plus the long weekends of Memorial Day, Fourth of July, and Labor Day. These thoughts remind me of an animated cartoon that I loved as a kid called the Grasshopper and the Ants, an ancient fable of Aesop recast by a young Walt Disney in 1934 in The Silly Symphony (you can find it on YouTube – it runs 8 minutes).
The gist of the story was that a grasshopper had fun and played all summer, while the neighboring ants aligned industriously to work throughout the sunny days storing up food and preparing for winter. When winter came, the cold and hungry grasshopper realized his sorry situation and came begging to the ants for food and shelter. According to Disney’s version, after a momentary reprimand the ants kindly took in the pitiful grasshopper who then entertained them with his fiddle over the winter. In the Aesopian corpus this story is The Cicada and the Ant (classified as Perry 373). The simplistic moral to the story is a useful lesson for children, but humans, unlike ants, need vacations; motivations in the human sphere differ from those in ant land.
[EOW by DAB 2002]
Ants and humans, E.O. Wilson teaches us, are among the very rare eusocial species on Earth. These colonial animals live in multi-generational groups where most individuals cooperate to advance the public good and to perpetuate the species into the next generation. In effect, their colonies are superorganisms that transcend individual biologic lives and create civilizations turned over to successive generations. The meaning of individual lives, then, is simply to be found in their contribution to their tomorrow and the tomorrows of their successors. Ants accomplish this work by communicating via pheromones, chemical signals that Wilson and his collaborators elucidated. Pheromones, added to genetic and epigenetic capabilities, vastly enhance the ability of eusocial organisms to deal with and transmit information. The human luck of spoken and written language allows us to process information (sensory, narrative, and numeric), work cooperatively, and create new information that we deploy and pass along to successive generations. The cultural and scientific ways of thinking that emerged from language have produced creativity that has changed the Earth. Whereas internal motivation and environmental pressures inspire personal creativity, it is largely personal and political freedom that allows its dissemination, thereby expanding civilization intellectually and materially.
It is a beautiful thing to see people acting in harmonious synchrony. This picture I took outside the de Young Museum in San Francisco this spring shows a display of T’ai chi (太極拳), a Chinese martial art practiced for its health effects, focusing the mind for mental calm and clarity. No pheromones or visible rewards motivate this alignment, the motivation is internal. T’ai chi is lovely to watch, the harmony and synchrony registering pleasurably in the hardwiring of our brains. This is the stuff of art, the deliberate work of other people that we admire and that sometimes astonishes us. You can find beauty in a myriad of other aligned performances. The Stanley Cup playoffs are one example of exquisite and harmonious alignment of teams. Surgical procedures may fall into this realm; it’s interesting that in Great Britain the operating room is referred to as the surgical theatre. When synchrony is harshly enforced, however, as in the dark vision of industrialism depicted by the Diego Rivera murals in Detroit or the failed experiments of communism, alignment is not so pretty.
The cartoonish stereotype of disheartened industrial assembly line workers in the Rivera murals has been reinforced by generations of business schools and accounting management ideology. The belief was that managers should determine work-flow methodology and set production targets as if assembly lines were machines to be sped up or slowed down as managers deemed necessary. This is the essence of accounting-based management. The Toyota Process System, now embraced world-wide by forward-looking businesses as lean process methodology, turns this paradigm around, having shown that where workers are empowered to think, innovate, and take pride in their work, better products, greater efficiency, and customer satisfaction will result. Ironically, Toyota’s innovation was initiated over 60 years ago when the company’s founder visited Ford’s massive River Rouge plant just as Japan was rebuilding its industrial base after WWII. Where the American managers saw one thing in the Ford assembly line, the Japanese leaders saw something completely different. The following quote explaining “What Toyota saw at the Rouge” comes from an excellent book called Profit Beyond Measure, by H. Thomas Johnson and Anders Bröms: “When Eiji Toyoda told Philip Caldwell that Toyota had discovered the secret to success at the Rouge, his comment implied that what Toyota had perceived about operations at the Rouge was very different than what Caldwell and his Ford colleagues or their counterparts in the other Big Three auto companies had seen. For one thing, it seems that Toyota people did not view low cost at the Rouge in terms of its scale, its throughput, or its managers’ effort to impose external targets for speed and cost on workers in the plant. Instead, they seemed to perceive a holistic pattern permeating every minute particular of the system. On one level, the pattern that caught Toyota’s attention was the overall continuous flow of work in the Rouge as a whole. But at a much deeper level, they observed that work flowed continuously through each part of the system – literally through each individual work station – at the same rate that finished units flowed off the line.” (Caldwell was President of Ford at the time.) Toyoda saw an organic self-learning system in the assembly line, where expertise at work stations is continuously harvested by motivated workers to improve work flow and product. Jeanne Kin and Jack Billi floated this book to my attention a few years ago and it continues to strongly impact my view of organizational systems.
4. Just as modern industry is embracing the concepts of Toyota Lean Processes, health care systems in their frenzy to cut costs while complying with increasingly onerous regulation are oddly embracing the failed experiments of management accounting that impose cost and throughput targets on health care providers. Data (numeric information) should inform decisions whenever possible, but it cannot be the sole driver of key operational choices. All data must be viewed as suspect for, after all, the numeric information we produce for ourselves is merely an artifact of human invention: numbers and their manipulation may or may not reflect reality accurately. Intense focus on data tends to obliterate stories (narrative information). Truth is elusive and while stories can be just as false or misleading as data can be wrong or misinterpreted, when stories resonate with truth, prove to be genuine, or otherwise offer value they get repeated and stick around. While the accounting mentality examines data for consistency and at its best extracts useful stories from data, the scientific mentality examines and hypothesizes stories and then seeks data to support the story and create a better one. Accounting is a matter of numbers, but science is ultimately a matter of stories. The human brain is hard-wired to relate to meaningful stories, and those ancient ones that endure, such as The Iliad, The Odyssey, and the Bible, endure because they give artful evidence of larger truths, exemplary behavior, or experiences that we keep repeating. Some stories are extremely succinct, but have enough truth that we keep repeating them like: Pythagoras’s story that for a right-sided triangle the area of the square on the side opposite the right angle equals the sum of the areas of the squares of the other two sides. Another durable story is that the area within a circle is its radius squared times an irrational number called pi.One might argue that by its very substance this story is irrational, but it sure seems to have held up through time. A newer story tells of the ultimate connection of light, matter, and energy, that is, is e=mc2. These stories seem to be true and have found their Darwinian niche in the human narrative.
5. We are indoctrinated by stories since childhood. Fables, short stories with moral lessons, typically feature animals with human qualities. Aesop, supposedly a slave in ancient Greece (620-560 BC) a generation after Pythagoras and a century prior to Hippocrates, is the fabulist best known in the Western world. It is an astonishing demonstration of Darwinian durability that his fables have been repeated to children in most languages for well over 2500 years. Ben Perry, the 20th century authority on Aesop, indexed and edited Aesop’s stories for the Loeb Classical Library in 1952. One of the half dozen fables dealing with health care is The Old Woman and the Thieving Physician. This may have been added to the Aesop corpus rather than an original of the actual fabulist. The tale involves an elderly lady with sore eyes who asks a physician to cure her from anticipated blindness, but her deal was that payment had to await cure. The doctor made repeated house calls to apply salves and with each visit stole anything he could take away from the house. Once the cure was competed the woman refused payment saying that her sight seemed to be worse than ever since she now couldn’t see or find any of her household property. This characterization of the dishonest physician was number 57 of the Perry Index.
6. Ben Perry was born in 1852 in Fayette Ohio and received his B.A. in 1915 from the University of Michigan and a Ph.D from Princeton in 1919. His early academic posts took him to Urbana Ohio University, Dartmouth, Western Reserve, and then, for the bulk of his career from 1924-1960 at the University of Illinois. He returned to Michigan as visiting professor in 1967 and died back in Urbana, Illinois in 1968. Perry concentrated his work in two minor genres, the fable and the ancient novel. The Perry Index includes all fables related to, ascribed to, or connected to Aesop and goes from #1 The Eagle and the Fox to #584The River-fish and the Sea-fish. In addition, the Extended Perry Index goes from #585 Sick Lion, Fox and Bear to #725 Fish from Frying Pan into Coals. Curiously Aesop offered tales of all sorts of creatures and many occupations, but only the occasional doctor’s story in addition to the ophthalmologic case: #7 Cat as Physician and the Hens, #114 The Physician at the Funeral, # 170 Physician and Sick Man, #187 The Wolf as Physician, or #289 The Frog Physician, and #317The Unskilled Physician. Some of these were matters of impersonations while others like #57 above were character studies of the profession. Perry #427 was the classic Fox and Hedgehog story, resurrected for our time by Isaiah Berlin.
7. The Art Fair is a special time in Ann Arbor. I lived here for about 10 years before I ever walked around in it – summertime is busy for those who take care of children, pediatric urologists included. In 1997 we started the John Duckett Lecture in Pediatric Urology, in honor of a colleague and a friend of Michigan Urology who had passed away that year. The idea was that this would take place on the Friday morning of the Art Fair, and we would close up most of our clinical and research work for the day. Our staff would simultaneously have Staff Education Day in the morning and the afternoon free for the Art Fair or whatever, as their annual birthday present. Over the years we have expanded the intellectual part of our Art Fair week with the Chang Lecture on Art and Medicine Chang on the Thursday and usually added a Lapides Lecture to the Friday session. This year we asked one person, Pierre Mouriquand from Lyon France, to do both the Chang and Duckett Lectures. In effect this was asking Pierre to walk a tightrope between two intellectual towers, and he navigated the line beautifully. As a great pediatric urologist and a painter of substance and daily practice, he is well qualified on both fronts. The Chang Lecture consisted of Pierre’s story Slowly down the Rhône: the River and its Artists. He produced a magnificent talk bringing together not only art and medicine, but also geography.
His Duckett Lecture was Understanding the Growth of the Genital Tubercle: Why it is relevant for the Hypospadiologist. Here he showed his mastery of the field with a brilliant update on embryology and challenging thoughts on surgical reconstruction of difficult dysfunctional anatomy. He fielded a series of case presentations from residents and later in the day attended our Disorders of Sex Development (DSD) team meeting and lunch, where he challenged the modern terminology and presented some videos that showed new concepts in reconstruction. In the evening at dinner our residents and the pediatric urology team got to know Pierre and his wife Jessica mixing technical talk, health systems discussions, and seeing how a couple successfully navigates the challenging world of life, family, and academic medicine.
Regarding this first academic event of the new season of residency training (also called Graduate Medical Education or GME) I need to invoke a sports metaphor and say that “Pierre hit it out of the park.” Events like these fulfill the essential duty of the university: sharpening inquisitiveness, disseminating ideas, widening cosmopolitanism, and educating our successors.
8. Chang Lecture on Art and Medicine 2016. Our speaker next year will be Don Nakayama, former chair of the Surgery Department at West Virginia. He wrote an interesting article in Pharos last year on the Diego Rivera murals at the Detroit Institute of Arts. [The Pharos 77: 8, 2014] Perceptively, he recognized that the so-called Surgery Panel on the South Wall was not a depiction of “brain surgery” as art historians have claimed, but rather an illustration of an orchiectomy, a procedure much more attuned to Rivera’s view of the Rouge Plant workers. It is a great testimony to the vision of Edsel Ford to have brought Rivera, arguably the world’s best muralist of the time and an ardent communist, to Detroit to produce the work in 1932. Things didn’t go so well later in New York City when Rivera tried to repeat the experiment with the Rockefellers, but that’s another story.
[Lower right mural on the South Wall: the orchiectomy]
Caleb Nelson will be doing the Duckett Lecture and Bart Grossman will be doing the Lapides Lecture next year for an all-Nesbit Line up on that Friday of the 2016 Art Fair.
9. Disney’s Silly Symphonies also included The Wise Little Hen, a version of a Russian folk tale more popularly known as The Little Red Hen. The nugget of the story was that the hen finds a grain of wheat and asks the other animals on the farm to help plant, grow, and harvest it. None chose to help, but after she harvests the wheat she asks again for help threshing, milling, and baking, but none step forward. After the bread is done, she asks who should help eat it – and of course everybody volunteers. The hen, however, says sorry “if any would not work, neither should he eat.” (The Wise Little Hen included the debut of Donald Duck.) President Ronald Reagan referred to this story in 1976, citing a politicized version in which the farmer chastised the hen for being unfair. After the hen was forced to share her bread, she lost the incentive to work and the entire barnyard suffered. This twist on the story made it a cautionary tale slamming the welfare state. While the story teaches children the importance of doing their part in terms of the daily work of the community it lacks the complexity of reality. Modern society is far more complicated than a barnyard and the line between personal responsibility and public beneficence (i.e. government) is tricky to arbitrate. Furthermore, many in society experience tragic bad luck beyond their control or are unable to assume personal responsibility. Reagan’s farmer had the un-antlike characteristic of compassion, a human quality that must have long-preceded even our biblical days. A society has to nurture personal freedom, creativity, and individual responsibility if it is to be successful, but without kindness and compassion a civilization is not a human one. After all, when Disney anthropomorphized his ants he gave them not just language, but also compassion.
Where do we draw the lines regarding personal freedom and such things as immunization mandates, smoking, drug use, obesity, and dangerous behavior? Should motorcyclists have to wear helmets? How do we provide health care to the indigent and incapable? How do we create health care equality and affordability? These questions ultimately get arbitrated in the political arenas regionally and nationally, generation after generation. Our nation walks on a tightrope between the cartoonish ideologies of the welfare state and what some might call individualism, capturing the beliefs of libertarianism, laissez-faire capitalism, and ethical egoism. Obviously neither the welfare state nor any “ism” has it right – the best path for a just, creative, and cosmopolitan civilization is a path in between the cartoons. The bad news of today (and maybe this is the bad news for every human era) is that cartoonish people find their ways to leadership and compel the rest of us along irrational paths that threaten the future we want to turn over to our next generation. All citizens need to step up their understanding of the issues of public policy and health care as well as involving themselves in its regional and national discussions. We can no longer let politicians, accountants, and pundits alone shape the critical decisions.
10. Funambulism. On this day, August 7, in 1974 a 24-year old Frenchman named Philippe Petit walked across a high wire he had rigged between the Twin Towers of the World Trade Center. He actually crossed the wire 8 times, performing for 45 minutes to the amazement of on-lookers in the towers. He must have looked like an ant to those on the ground, and vice versa. Petit’s funambulism represents a perfection of self-alignment in terms of balance that few can achieve, yet it is also an astonishing display of self-confidence, clandestine preparation, and admirable civil-disobedience. Curiously funambulism defines tightrope walking and a show of mental agility interchangeably. Few can deny that serious tightrope walking is as much a matter of mental as physical agility and you have to admire the internal drive that motivated Petit to accomplish this heroic feat. That was art.
Postscript: With the start of August we saw the retirement of Jack Cichon, our departmental administrator, and Malissa Eversole is now steadily in place on the job. Jack managed the business and operational affairs of Michigan Urology for 20 years with great loyalty, integrity, and (at some challenging times) extraordinary courage under pressure. He becomes an honorary member of the Nesbit Society and we hope to continue to see him in the course of our departmental events, noting his broadened smile of relief from the administrative pressures of the University of Michigan Medical School and Health System that he served so admirably.
Thanks for spending time with What’s New and Matula Thoughts.
David A. Bloom, MD
Department of Urology, University of Michigan Medical School