Rules, boundaries, and stories
DAB What's New June 1, 2018
Rules, boundaries, & stories
Colors explode as summer opens up in June around Ann Arbor. The visuals are unsurpassed in the UM Nichols Arboretum Peony Garden, adjacent to Mott Children's Hospital. The garden is a few years short of a century old and derives from Dr. WE Upjohn's flower collection (pictures above and below, May 29, 2018).
Schools let out in June and summer vacation begins for most students north of the equator, echoing our agrarian history when children needed to be free to work on family farms. Today, farms don't depend on child labor and most schoolchildren come from urban/suburban homes, the rural: urban ratio having flipped in the last 150 years. In 1870, 25.7% of the US population (38.5 million) was urban and 74.3% was rural, while by 1990 the ratio was 75.2% urban and 24.8% rural (population 248.7 million) and the trend continues, although summer vacation still rules in most schools and workplaces. [Table 4 US Census Data 1993.]
Doctors in training don't get summers off, they have full 12 month cycles of education, with one random month for vacation, and our new cohort begins its turn next month here in Ann Arbor. [Above: Grand Rounds.] Time has framed graduate medical education in urology since the formalization of the American Board of Urology in 1935. Urology trainees at Michigan spend five years of postgraduate training after medical school, shorter than my time of residency at UCLA, although residents today are increasingly likely to put in additional years for fellowship training. The idea of "duty hour" limitation was a reaction to a few bad training programs that exploited residents, and the 80-hour work week is the national standard for residents in training. Another quantitative constraint is the concept of minimum numbers of specific operative procedures.
A qualitative dimension of regulation, educational milestones, was implemented within the last decade. Milestones reflected the enticing idea that GME should not routinely progress only according to clock, calendar, and case numbers, but according to acquisition of skills. The increased burden of administrative time and paperwork to document milestones, however, has been unmatched by any demonstrable value for trainees or programs and, if common sense prevails, milestones will likely get swapped out for another idea or experiment. Nonetheless, it is clear that time and numbers alone should not be the only measures of residency education.
Our new GME cohort. Residents Kathryn Marchetti from UM, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Fellows Giulia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO). New Faculty: Bryan Sack from Boston Children's Hospital and Courtney Streur who completes her pediatric urology fellowship both join our Pediatric Urology Division. Kristin Chrouser has joined our faculty this year from the University of Minnesota in NPR and will be mainly at the VA.
Time, curiously, has no role in baseball, the game of summertime. The sport has no relation to a clock – rather milestones of innings, runs, and outs mark the game's progress. In this, baseball lends itself to being the ideal summer sport, unfettered by time and limited only by accumulation of three failures or "outs" and innings unless bad weather intervenes or until it gets too dark to play.
Baseball at Night, a painting by Morris Kantor on display at the Smithsonian American Art Museum in Washington, DC, shows a minor-league game in West Nyack, NY, around 1934. Stadium lighting was a rarity then, given the long days of summer when play could continue until dark, although twilight made the game tenuous. Stadium lights shifted quickly from novelty to necessity and major league teams have played deliberate night games since 1935.
It's hard to imagine baseball or any other sport without limits and rules, even if arbitrary or parochial, such as the designated hitter rule that now applies to one major league but not another. Rules matter and when different leagues play each other, they find it necessary to have rules that supervene their particular league rules. Rules create fair playing fields, allowing games to go forward and conclude peacefully.
Rules are equally essential for other social activities, organizations, and governments. The USA has the Constitution and Bill of Rights. The State of Michigan has its own constitution and laws, including term limits that guarantee frequent refreshment of the state legislature, but at the expense of deep institutional knowledge of the state and its components. The University of Michigan has its Regent's Bylaws and Standard Practice Guide, as well as Michigan Medicine's own sets of Bylaws. In all of these we rely on consensus for decisions, achieved casually in daily operations, more formally in committees (using Robert's Rules of Order), and more broadly by public voting.
Communication skills are a pre-requisite for medical practice in both the essential transactions of direct patient care and in the complex team play of modern specialty medicine. [Above in foreground, Brent Williams, Professor of Internal Medicine, communicating with Michael Giacalone, Jr., Chief Medical Officer of the Hamilton Community Health Network in Flint.] Listening, speaking, reading, and writing skills are taught with variable degrees of success in elementary schools up through college, but medical practice demands more vocabulary and capabilities. Medical students, it is said, double the size of their vocabularies.
The traditional algorithm of healthcare starts with listening to the concerns of patients and then probing for additional information to construct a medical history, including relevant comorbidities and circumstances. Patients are physically examined and data is assembled into coherent narratives. Diagnosis, prognosis, and therapy derive from those stories in which authenticity and accuracy are assumed.
Modern electronic systems impose new communication challenges. Email and texting are immediate and convenient, but lack the human factors of facial cues, thoughtfulness, and social grace. Electronic medical records (EMRs) constrain work flows to templates and replace human narratives with check lists, pop-up choices, keyboard entries, and cut-and-paste phrases. The actions of data entry detract from listening, looking, and communicating with patients. Healthcare processes today do not prioritize stories, and it seems to me that appreciation of the art of the story lies at the heart of excellent clinical care. It's no great leap of faith to claim that the art of authentic storytelling and story construction is the basis of most human relations, from compelling stories around campfires to A3 storytelling in lean process engineering. Truth and authenticity matter. Listening to them and weaving them are art forms.
Physician-author William Carlos Williams appeared on these pages earlier this spring and since then I've been thinking of the different contexts in which physicians write, and first and foremost, physicians write the stories of their patients.
Williams, you may recall, was the author of Spring and All of which a recent edition included an introduction by C. D. Wright comparing Williams to an earlier poet from New Jersey, Walt Whitman: "Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers." [Spring and All. WC Williams. New Directions Book, 2011.]
We pursue that greater human understanding on a daily basis, working in medicine, through stories learned and experiences gained, patient-by-patient. The dilemmas of patients are understood in terms of their stories, that must be heard, elucidated, and constructed from evidence and reasoning on the part of those who undertake the responsibility for helping. Stories are important to people, and we dignify them with our attention.
Electronic medical records are poor platforms for authentic narratives. The construction of narratives in the minds of physicians and the translation to visible words in some medium is a core element of the profession of medicine, framing the response of the care-giver in terms of advice, reassurance, therapy, and prognosis. This is the central organizing feature of the doctor-patient relationship, comprising the daily shop-talk of medical practice. A story must be accurate, with true facts, but also authentic, in reflecting circumstances and co-morbidities (an economist might call these externalities) framing the "present illness" and creating a context for further conversation and therapy. In my experience, an authentic and empathetic story only fully emerges after the history, physical exam, and further discussion with patient and family.
My own clinic notes were once written or dictated well-after the clinical visit when the story was relatively complete and coherent. The reduction of clinical notes to formulaic elements such as the SOAP format (subjective, objective, assessment, and plan) or the E&M format (Evaluation & Management: chief complaint, history of present illness, review of systems, etc.) fits computer entry systems nicely, but has disrupted the traditional medical work-flow that create stories.
It is challenging to find the words to describe this fundamental type of medical writing whether in narratives or EHR. Quotidian medical communication seems to fit, even though not everyone is familiar with the use of quotidian for daily or routine. Quotidian communication must be accurate, truthful, and authentic to each patient. Most healthcare workers are writers and their products are stories of patients. A brief piece in The Lancet by Roger Kneebone called "The art of conversation" expresses the idea of the clinical conversation that we have clumsily called "taking a history." Kneebone expressed his thoughts more elegantly than I have, so I'll just quote two sentences and refer you to the rest. [The Lancet. 391:731, 2018.]
"A conversation is a one-off live performance that can never be repeated. Its essence is its evanescence, and attempts to capture in writing are as thin as reading the script of a play or film."
Stories suffuse all types of medical writing. Scientific writing for journals, grants, or textbooks is the bedrock of healthcare research and progress. Just as with stories of patients, this writing is predicated on accuracy, and clarity is enhanced when a meaningful story is constructed from the science. Medical journalism, another form of medical writing, communicates to the public about medical science and practice. Medical memoir is another important genre, also written for the public but usually as personal storytelling or essays.
William Carlos Williams and others divert into creative reflections through prose and poetry. These writers mainly tell stories they create, often based on authentic experiences, but with "literary license." Many of these physician-writers venture into fiction at the other end of the spectrum of medical writing, although this too requires authenticity in that stories revolve around individual experiences, conflicts, tensions, issues, and environments that are genuine to the reader's senses. The fictions may involve other species or galaxies, as with the work of Michael Crichton, but if the stories are well-crafted they contribute to that greater authentic human understanding. To summarize medical writing variants: a.) the daily writing of clinical practice, b.) scientific writing, c.) medical journalism, d.) medical memoir, e.) creative reflections, and f.) fiction.
We are a species of stories and understand ourselves through stories far better than through data. That greater human understanding is accessed through narrative better than through numbers. The novelist Kazuo Ishiguro, in his 2017 Nobel Prize Lecture, praised the "… quiet private sparks of revelation …" to be found in stories. "Stories can entertain, sometimes teach or argue a point. But for me the essential thing is that they communicate feelings. That they appeal to what we share as human beings across our borders and divides." [Ishiguro. My Twentieth Century Evening and Other Small Breakthroughs. AE Knopf. NY 2017.]
A pig story. It doesn't take much to disturb a comfortable status quo or otherwise disrupt peaceful human relations. An obscure story exemplifying this began on June 15, 1859 on San Juan Island, a place east of Vancouver Island where both the United States and Great Britain claimed sovereignty, after the Oregon Treaty of June 15, 1846, exactly 13 years earlier. [Below: blue Haro Strait boundary favored by US, red Rosario Strait favored by Britain, green compromise proposal. Copyright Derek Hayes, Historical Atlas of the Pacific Northwest. Sasquatch Books, Seattle, 1999.]
Peaceful co-existence remained in play until a British pig, owned by Hudson's Bay Company employee Charles Griffin, wandered onto an American farm to eat some potatoes. This wasn't the first transgression and Lyman Cutlar, the American farmer, shot and killed the trespassing pig. Cutler's offer of $10 compensation was refused and the British threatened to arrest him. Sixty-six American soldiers under the command of Captain George Pickett were dispatched to the island to prevent British forces from landing. The British countered, bringing three warships offshore, soon escalating to five ships, 70 guns, and 2140 men. American forces then swelled to 461 men with 14 cannons, as diplomacy failed and the dispute escalated into The Pig War. The British governor of Vancouver Island ordered Rear Admiral Robert Baynes to land his marines on San Juan Island, but Baynes wisely refused to further escalate the "squabble over a pig" and the war remained bloodless, aside from the porcine tragedy.
In October, President Buchanan sent General Winfield Scott to resolve the crisis and negotiations resulted in an agreement that the British could occupy the north half and the Americans the south with each side allowed up to 100 troops pending further formal agreement. No wall was built, and in 1872, a full 13 years after the ill-fated pig, an international commission led by Kaiser Wilhelm I, decided that the entire island should fall under American control and so it remains.
Henry Martyn Robert was one of the 66 American soldiers stationed on San Juan Island under Pickett's leadership. It's hard to know how he felt about his mortal jeopardy over the cause of a pig, but it's a good thing the conflict remained bloodless and Robert went on to bigger things. Born in Robertville, South Carolina, he grew up in Ohio where his family moved due to their opposition to slavery. Robert's father, Reverend Joseph Thomas Robert, would later become the first president of Morehouse College (1871-1884). Henry went to West Point and graduated fourth in his class in 1857, becoming a military engineer and building the fortifications on San Juan Island in 1859. He remained with the North during the Civil War, attending to defenses around Washington, Philadelphia, and New England Harbors. After the war, he served the Army Division of the Pacific from 1867-1871, then developed ports in Wisconsin and Michigan, later improved harbors in New York and Philadelphia, constructed locks and dams in Tennessee, and performed more civil engineering pertaining to the Mississippi River and Hurricane Isaac in Galveston. He died in 1923 and is buried at Arlington. [Below: Brigadier General Henry Martyn Robert, Wikipedia.]
Although Robert's military service was significant, we remember him today for his civil engineering of practical rules for human interaction. These came about in 1876 after losing control of a church meeting he was leading in New Bedford, Massachusetts when it erupted over abolitionist views. Robert blamed his ineptitude for the fiasco and decided to teach himself how to run a meeting. His study of the procedures of the House of Representatives led to his Pocket Manual of Rules of Order for Deliberative Assemblies. He wrote:
"One can scarcely have had much experience in deliberative meetings of Christians without realizing that the best of men, having wills of their own, are liable to attempt to carry out their own views without paying sufficient respect to the rights of their opponents."
Robert's world was framed by his gender and faith, but his rules have endured because they are independent of his particularities. Robert's Rules of Order apply to almost any human gathering and, like the rules of baseball, Robert's Rules level the playing field and allow the game to go forward. ["Historical Vignette 038 – An Army Engineer Brought Order to Church Meetings." U.S. Army Corps of Engineers – Office of History. November 2001. Retrieved 2015-12-02.] His rules offer protocols for civilized and democratic behavior.
Michigan hosted its first Teeter Symposium last month, focusing on bladder cancer in honor of our Ann Arbor friend Bob Teeter, who died a decade ago from bladder cancer in spite of radical cystectomy. [Above, Bob and Betsy Teeter; below, Teeter Laboratory Plaque.]
Since then, knowledge and therapy of bladder cancer have increased by a quantum leap, although more leaps are necessary to obliterate the pain, suffering, and mortality of that disease. The day-long event, organized by Alon Weizer, featured 2 guest speakers and held an attentive audience that topped 50, with excellent talks and superb discussions. The event fulfills one of the items on my bucket list as department chair and honored not just Bob and his surgeon Jim Montie, but also some generous gifts for laboratory investigation that we gained after Bob passed away.
The first guest lecturer, Thomas Bender, MD, PhD (above) from Dow Chemical, spoke about the Health Hazard Evaluation Program for former employees of a chemical plant that had been closed in 2002, but Dow later acquired its parent company, Morton, in 2009. As I sat in the audience, wondering how to link this month's Matula Thoughts to the Teeter Symposium, Dr. Bender said a magic word: Paterson. That's where the chemical plant had been since 1929. Paterson, New Jersey, was the home of William Carlos Williams.
The next invited speaker, Elizabeth Plimack MD, MS, Chief of Genitourinary Medical Oncology at Fox Chase Cancer Center, grew up in Ann Arbor. Her parents and mentor Richard Swartz were on hand to hear her excellent talk Immunotherapy and Beyond. In attendance was Monica Liebert (Nesbit 1984 below), now retired, but still working in our laboratories. Monica developed many bladder cancer cell lines in her heyday and these are still utilized in our research efforts.
Our own Khaled Hafez (below, Nesbit 2004) closed the event with a superb talk on Clinical Management of Patients with Locally Advanced Bladder Cancer, a topic close to his heart and emblematic of his skill set, as he is surely one of the best in the world at this craft.
The AUA annual meeting last month in San Francisco featured the usual strong Michigan presence. San Francisco was also the site in 2010 where the picture of our inaugural chair, Jim Montie (Faculty Nesbit 1995), was taken. In addition to turning over a very strong group of faculty and department, in 2007 when the current departmental administration began, Jim turned over a positive team culture, rather than a "me-me-me" culture. Jim not only remained relevant to the department, but remains a keen participant and a role model of leadership.
Looking through those 2010 Nesbit reception pictures, I found a picture of the late and truly great Cornell Urology Chair, Darracott Vaughan, flanked by Jennifer Anger of UCLA and Hunter Wessells, chair at the University of Washington in Seattle (below).
But now back to 2018.
Above: Emilie Johnson, Nesbit 2011, with her iconic mentor from Boston, Alan Retik. Below: Julian Wan, Nesbit 1990, at one of his podium appearances, knocking it out of the park.
[Below: Music reception with Khurshid Ghani, Faculty Nesbit 2013, & David Miller, Nesbit 2005.]
The Nesbit reception this year at the Hotel Vitale on Mission Street hosted around 100 alumni, friends, and current team of the Urology Department. Below, a partial view of the crowd.
[Above: Damon Davis, Nesbit 2007. Brian Sack will start with us in pediatric urology this summer. Kristin Chrouser joined us this winter from Minneapolis and is centered at the VA. Below: Irene Crescenze current fellow FPMRS, Cheryl Lee, Nesbit 1997, now chair at Ohio State, Bert Chen, Nesbit 2006.]
[Above: Stu Wolf, Faculty Nesbit 1996, now in Austin, Udit Singhal PGY 2, Alon Weizer Faculty Nesbit 2005, Bunmi Olapade-Olaopa Nesbit, 2000. Below; Betty Newsom, Nesbit 1990, Bart and Amy Grossman, Nesbit 1977.
[Above: Lynda Ng, Nesbit 2005 and Jerilyn Latini, Faculty Nesbit 2003. Below: Steve & Faith Brown, friends of Michigan.]
[Above: Tom Stringer, Dept Urology Florida, Barry Kogan, Nesbit 1981 and Chair Albany. Below: Hugh Flood, Nesbit 1991, of Clonlara, County Clare, Ireland. Below: Simpa Salami, Nesbit 2017 & guest Mohamed Jalloh of Dakar, Senegal.]
Boundary matters. A few months past the JAMA column, A Piece of My Mind, came from Jeffrey Milstein at Penn Medicine [Milstein. The envelope. JAMA. 319:23, 2018] and detailed his office visit with a 70-year-old patient who carried a large white envelope, assumed to be "outside records." Most of us get these, not infrequently, indicating that a second or third opinion is expected. On the occasion of this particular visit, the details were those of a 32-year old son who had recently passed away due to cancer. The envelope contained a stack of records with an obituary on top. The patient first wanted to talk about his son and then the course of his disease, tests, hospitalizations, treatments, and emotional toll. Then, after "a long moment of silence" the patient explained that he himself had not been to a physician in years, but needed to tell his son's story before committing to his own care. The clock had run down by then and "the time for the visit" was over leaving nothing that could be documented in the EHR about the patient himself. The author noted "so another visit must be scheduled."
So, it seems medical care today has tight boundaries of time and information. Boundaries for nations, sports, politics, education, business, are important, but some are more important than others. The Pig War, a foolish dispute, easily could have escalated to bloodshed, leaving us no Robert's Rules. Rules and boundaries in sports allow games to proceed fairly and end peacefully. Some boundaries in health care are tight and timeless, as evidenced in the Hippocratic Oath or as shamefully dishonored by occasional bad actors. The constraints of the EHR are self-inflicted wounds of the business of medicine, and should be viewed with minor contempt and never honored at the expense of a patient.
Baseball, timeless as it is, nonetheless must be somewhat mindful of the clock. Some fans may have babysitters, while transportation drivers and other workers are paid by the hour. The number of pitches thrown is a clock of a sort. Still, the essence of the game is indifferent to time. The same is true for conversations with patients. Life and schedules are much easier when each patient's visit goes according to clockwork precision, but the essential transaction of the crucial conversations not infrequently runs afoul of anticipated timed encounters. These conversations are unique in the human repertoire and can have the most profound implications. Skilled clinicians know when and how to diplomatically crowd the later patients, run through lunch, or regroup with an expansive patient later in the day or soon thereafter. Such is the art of medicine.
Thanks for reading Matula Thoughts this June, 2018.
Posted in Academia, Academic medical center, Ann Arbor summer, Baseball, Colors, Graduate medical education, Health care, Medical education, Medical humanities, Nesbit Alumni Society, Time, University of Michigan Health System, William Carlos Williams
Mays and blues
DAB Matula Thoughts May 4, 2018
Mays, blues, & other thoughts
Each May brings a sweet spot to Ann Arbor's calendar with mild temperatures, bright colors, chirping birds, and happy graduations. Foliage on the UM Medical Center 'Hill" is a welcome sign of May and a favorite sight, seen above from last year, is a weeping ornamental cherry with spectacular magenta flowers. It sits outside the dean's wing so enjoy it while you can, as that area is scheduled for demolition due to anticipated new construction. Magenta, a tertiary color and the complementary color of green, comes from mixing equal parts of blue and red on computer screens, midway between the two primary colors on a color wheel or with paint or crayons.
Maize & blue colors are prominent in graduations of the 19 schools and colleges of the University of Michigan this month. Michigan's official azure blue is not quite the bolder darker "Go-Blue" color so well-known through our athletic programs. Azure blue is halfway between blue and cyan. Wikipedia describes azure blue as the color of the sky on a clear day, although looking out the window on a recent flight to Seattle it seemed that the sky can have many shades of blue.[Below: sky & mountains south of Great Falls, MT, with 737 engine.]
Medical School graduation is a grand occasion at Michigan and rightfully so being a milestone of medical education, the moment of awarding the M.D. The ceremony, at Hill Auditorium next week, reconnects attendees to the roots of our profession. Even if you don't have a family member in the graduating class or are not a departmental chair sitting on the stage, the event is a lovely way to spend an hour or two on a springtime Friday, see the Michigan colors in the academic gowns and join a recitation of the Hippocratic Oath.
Resident and fellow graduation. Less widely recognized and less ceremonious. but equally important, is the career-defining milestone of a medical career, when residents and fellows celebrate completion of their training programs. Residency graduates are the capstone product of medical education, coming from the phase of graduate medical education (GME) that may exceed twice the time of medical school itself. Michigan has nearly two times as many residents and fellows in training as medical students at any moment and the education of all of them requires a large base of patients for clinical experience, especially at the higher levels of complexity. This is the key reason for the current expansion of Michigan Medicine; a referral base in the range of 4 million patients is necessary to support 2000 medical learners at Michigan Medicine, 28 of whom are in the Urology Department. Add to these nursing students, pharmacists, dentists, and others training and its clear how much depends upon a broad patient base.
[Urology graduation/Chief's Dinner, 2015 – UM Art Museum.]
Numerous trainee graduations of clinical departments are scattered throughout Ann Arbor this month and next. The graduates then quickly immerse in their fields of choice to become independent practitioners. In time, they will be the experts of their generation and in this lengthy and complex educational process, "The Maize and Blue," as the University of Michigan is informally called, is unsurpassed.
Urologists with Michigan roots comprise the Reed Nesbit Society, named after Michigan's first urology section chief. Later this May the American Urological Association (AUA) holds its annual meeting where we will host our Nesbit reception that Sunday night in San Francisco. If you are reading this newsletter, whether Nesbit alumnus or friend, you are welcome to join us, so please contact our office for details. Our Department of Urology will have a vigorous presence at the AUA, with well over 100 presentations of various sorts and our faculty are active in most leadership forums and arenas.
The AUA origin story begins with Ramon Guiteras, a prominent New York surgeon who had interest and skills in genitourinary surgery. After work one day in 1900 he took his team to an East Side tavern, The Frei Robber, that featured homemade wine and limburger cheese. The pungent cheese kept other patrons strategically away from the clinical shoptalk. Amidst the fruitful conversation, the group named itself the New York Genitourinary Society and decided to meet periodically.
Genitourinary surgery was then a facet of general surgical practice and some surgeons like Guiteras were consolidating the special skills, knowledge, and new technology of its practice. Guiteras proposed a new word for the field, combining the Greek terms for urine (uro) and study (logy) and it seemed to catch on, even if semantically it doesn't quite hit the mark of accuracy. Guiteras, no doubt, intended the word to capture the idea of the practice and study of the urinary (and genital tracts) as evidenced in his subsequent textbook of 1912.
The NY Genitourinary Society continued to meet at various locations. Two years later, assembling at the home of Guiteras, in February, the group renamed itself the American Urological Association, an intentional stretch, even though they all were New Yorkers. They held a "convention" in June, 1902 at Saratoga Springs. Membership expanded and the following year a second "annual convention" was held in New Orleans and a third in 1904 in Atlantic City, with 34 members in the convention photograph. In 1905 the group met in Portland, Oregon, reflecting the national growth.
By 1910, 320 active and 16 honorary members were listed and Hugh Cabot became president. His presidential address the following year, at the Chicago convention was: "Is Urology entitled to be regarded as a specialty?" Clearly, the Guiteras neologism had been accepted. Cabot's Modern Urology in 1916 was the second authoritative urology text in the 20th century, and Young's in 1926 would be the third.
Cabot's rhetorical question reflected daily tension in the workplace between general surgeons and genitourinary specialists, still widely considered "clap doctors." General surgeons resisted the loss of turf to a new cadre of highly skilled genitourinary surgeons like Cabot who were claiming the new clinical territory. Anesthesia, antisepsis, analgesia, and modern technology with electrical illumination, x-rays, cystoscopes, and precision instruments allowed the new breed of lithotomists to differentiate themselves. When Cabot came to Ann Arbor in 1920 he opened up the era of academic and modern clinical urology at Michigan.
Blues. Medical School and residency training graduations are highpoint in our circle of educational life. Above from the 2013 Medical School graduation you see current academic vice-dean Carol Bradford, former EVPMA Mike Johns in maize and blue, along with former dean Jim Woolliscroft.
While Michigan's maize and blue is far flung around the world, another shade of blue, that of Levi Strauss, is truly ubiquitous, visible every day, nearly anywhere you find people on Planet Earth. I felt a little creepy when I captured the street scene below, but I wanted a picture of an anonymous person wearing these universal trousers. Such is the nature of human beings, that if a centralized government mandated everyone to wear a blue jeans uniform, people would find any excuse and no doubt risk punishment to avoid the uniformity. Ironically, despite their pervasive presence, blue jeans are an expression of individuality and freedom to be casual, comfortable, and at liberty to choose from a variety of jeans that seems nearly infinite in terms of hues, logos, fit, manufactured wear and tear (often with holes and rips), as well as actual states of well-earned damage. Blue jeans seem to be a mark of a free society.
Cotton's utility is enormously important, but its production and manufacture tied to particular geographies came historically (and perhaps currently) at the cost of great human misery. Fustian, a heavy cloth woven from cotton, an odd word for most modern ears, is also used for pompous or overblown speech, deriving from cotton padding in clothing. The ancient city of Fustat, Egypt's first capital under Moslem rule, was a center for cotton manufacturing, although it's subsumed now by Cairo. Jeans, a trouser fabric, emerged from Genoa, Italy and Nimes, France. The term, jeans, may derive from Genoa. Denim, another cotton fabric, came from serge de Nimes. Dungaree was a thick cotton cloth allegedly named for a dockside village near Bombay called Dongri. Exported to England, dungri made good workman's clothing that were often colored blue, as were jeans. The coloring dye, indigo, mostly came from Pakistan, although American plantations became another large source until indigo synthesis was developed in Germany in the 19th century.
Levi Strauss, an 18-year old German immigrant, with his mother and 2 sisters in 1847 joined 2 older brothers who had begun a dry goods business in New York City. Strauss's name at birth (February 26, 1829) was Loeb Strauss, but he changed it to Levi in New York for ease of pronunciation. The family came from the Franconia region of the Kingdom of Bavaria, where Levi's birthplace is now a museum.
[Strauss home, Buttenheim, Bavaria. Source: Wikipedia.]
After a stop in Louisville, KY to sell dry goods, Levi became an American citizen early in 1853 and moved to San Francisco in March of that year to head the family's new shop in the epi-center of the Gold Rush. He lived with his sister Fanny and her family. The business, Levi Strauss Company, flourished, selling imported dry goods brought by ship to San Francisco and Fanny's husband, David Stern, helped run the firm. Jacob Davis, a Reno tailor who regularly purchased bolts of cloth to make clothes, wrote Strauss in 1872 to ask for help patenting a heavy-duty trouser with copper rivets at stress points at pocket corners and base of the fly. After trials of different materials, including cotton duck (a linen canvas), they settled on denim (Genoa style "genes") dyed blue. Davis and Strauss shared costs to develop the patent application and on May 20, 1873 US patent No. 139,121 was issued to Davis for "Improvement in Fastening Pocket-Openings." These were originally called "riveted waist overalls." Miners liked the durable trousers and "Levi's" soon became popular with cowboys as well. The company grew robustly. Strauss never married and after he died in 1902, he left his estate and company, worth around $6 million dollars, to his 4 nephews.
The same year Strauss got off the boat in NYC, a Philadelphia physician, Samuel David Gross, published a book in 1851 that marked the start of a new era for the practice and study of genitourinary diseases. Gross, at Jefferson Medical College, was the most prominent of a new era of general surgeons, empowered by the new tool of anesthesia and skilled with broad capabilities across the human anatomic terrain, including areas that would devolve to surgical sub-specialists over the next century. As it happened, Gross was particularly interested in the genitourinary system, and proved his mastery of the emerging field with his textbook, A Practical Treatise on the Diseases, Injuries and Malformation of the Urinary Bladder, the Prostate Gland and the Urethra.
Having exemplified one paradigm shift, Gross missed the boat in failing to take note of antiseptic surgical technique, in spite of Lister's convincing evidence published in 1867. The famous Gross Clinic painting by Eakins in 1875 celebrates Gross as a powerful surgeon, at first glance, but in fact calls him out as an "antisepsis denier" in contrast to the more rational Agnew Clinic, painted by Eakins 14 years later, coincidentally also in Philadelphia. Gross had no excuse, the conclusive antisepsis work by Lister in 1867 in The Lancet was well-recognized across the world. Gross obstinately led the American reaction against antisepsis saying in 1876:
"Little if any faith is placed by an enlightened or experienced surgeon
on this side of the Atlantic in the so-called carbolic acid therapy of Professor Lister."
This story was nicely told here at our Chang Lecture on Art and Medicine in 2014 by Charlie Yeo of Jefferson Medical College. Both Gross and Agnew embraced the belief that general surgeons, true to their adjective, should cover the entire anatomic terrain when surgery was necessary. Evolving technology and specialized knowledge would make it impossible for that paradigm to persist. Ophthalmology was one of the earliest modern specialties to find its own turf. Genitourinary surgery remained encompassed within general surgery for a longer time, even though a number of leading authorities in general surgery embraced genitourinary skills by the turn of the 20th century. New technical skills and specialty knowledge was exceeding the ability of most general surgeons to keep up across the entire anatomical terrain and the growing number of subspecialty experts craved conversations and identification with each other.
Festschrifts are academic celebrations to honor people and careers, and two of these coincided, in Seattle, for great genitourinary surgeons. By chance, after my arrival for these, I ran into Nesbit alums Atreya Dash and George Schade who had just emerged from a conference at the Fred Hutchinson Institute (below, Nesbit 2004, 2013).
The next day, Virginia Mason Clinic (VMC) celebrated Dr. Robert Gibbons who, among many other things, pioneered the indwelling ureteral stent. After service in Korea, Bob was recruited to the clinic early in his career by Nesbit trainees Tate Mason, Jr. and Roy Correa (Nesbit 1949, 1965). The Michigan/VMC relationship grew deeper with Bob Gibbons' mentorship of Jim Montie (below: Jim & Bob).
The day began with Grand Rounds at VMC, continuing through dinner on Mercer Island at the home of Kathy Kobashi (Section Head, Urology & Renal Transplantation) and Chris Porter (Uro-oncologist and Co-director of Clinical Research at VMC). Other VMC, UM, and personal connections emerged during the celebration. We saw Gary Kaplan, UMMS alumnus and the legendary VMC Chairman & CEO, who has returned many times to advise us in Ann Arbor (below: Gary, Chris, Kathy.)
John Ryan, VMC vascular surgeon, gave a wonderful talk on the use of the gracilis muscle in urology. We noticed him wearing a Nesbit Society tie from his dad, Dr. John Ryan (Nesbit, 1948). Steve Skoog, my friend since our days at Walter Reed and former chief of pediatric urology in Portland, OR (below) and John and Mary deKernion, friends and role models since my days at UCLA, were also on hand to honor Bob.
[Below: Jean and Mary DeKernion.]
Wally Gibbons, nephew of Bob and urologist in Wenatchee, Washington, came for the event. Wally's group recently hired Ian McLaren (Nesbit 2017) who we hear is doing very well, as Nesbit alumni do. [Below: Wally Gibbons, Bob Gibbons, Bob's daughter Jennifer Hayes, Jack McAninch, Kathleen Kobashi, Becky Schwaegler, Fred Govier, Jim Gasparich.]
The following day we celebrated Dr. Richard Grady, former UMMS student who became a pioneering pediatric urologist at Children's Hospital under the mentorship of Mike Mitchell, innovator of the transformational single stage exstrophy repair. Rich carried this technique, along with general pediatric urology, fearlessly around the world, to underserved and sometimes dangerous locations. Rich's event, held in the lovely University of Washington Research Buildings in downtown Seattle, featured friends of Rich from all over North America. It was a moving and richly educational day, highlighting Rich's skill as a surgeon, educator, and connector of people. His kindness, optimism, and social responsibility were extraordinary, seemingly coalesced into his sunny smile, right to the end last year when brain cancer cruelly interrupted Rich's life in spite of courageous therapeutic efforts.
Rich's last appearance at the AUA national meeting was in New Orleans (below, 2015) where he had a podium appearance wearing a head device that he cheerfully explained was "birth control for brain cancer" utilizing tumor-treating fields (TTF) for an antimitotic effect that interferes with glioblastoma cell division and organelle assembly by delivering low intensity alternating electric fields (below). A randomized clinical trial for glioblastoma with TTF and maintenance temozolomide involving 695 patients in 83 centers found a median progression-free survival of 6.7 months in the TTF group vs. 4.0 months in those without the electricity, with corresponding improvement in median overall survival, a small but meaningful step. [Stupp et al. JAMA. 318:2306, 2017.]
Rich and his wife Laura moved to Southern California for another clinical trial (Chimeric Antigen Receptor T cell therapy) at City of Hope where he was the first patient to complete the treatment that, in fact, melted away his tumors, although the effect was not durable. Nonetheless, the astonishing result was an important increment of progress. Honoring Rich were Dave and Sue Bomalaski (Nesbit 1996) from Anchorage, where, Dave after retirement from the Air Force, practices with the Indian Health Service. Mike Mitchell from Milwaukee and Joe Borer from Boston are seen below on either side of Dave (below).
[Above: Grady Festschrift group photograph.]
Hospice is an important part of healthcare. Most of us in the business of healthcare go to great lengths to avoid speaking of death. We want to be optimistic saviors of life and are uncomfortable speaking directly of its end. Having had little or no training in terminal life, we offer no more to our current trainees. Fortunately, our geriatric colleagues, palliative care experts, and hospice teams are uncommon exceptions to the rest of us. Rich's last days were eased by hospice care as were those of a good friend, John Reed, former UM Law School Dean and neighbor of Dr. Chang, who passed away recently, having nearly reached 100 years of age with full capacities until the end of 2017.
Australian writer, Cory Taylor, published a noteworthy memoir two years ago, detailing her struggles with melanoma since 2005, noting among other issues that a metastasis obstructing her urinary tract "necessitated the insertion in 2011 of a plastic stent to keep my right kidney functioning." She didn't report further urinary tract issues, so presumably the stent was changed periodically and kept that area of her anatomy out of harm's way.
Her book, Dying: a Memoir, confronts a phase of life that most people will experience, unless their death is violent or otherwise totally unexpected. Taylor's writing is lucid, frank, and lacking in self-pity. I found the memoir unexpectedly comforting. As Taylor looked back on her life, toward the end, she objectively examined its many positive memories, and voiced particular regrets but didn't let them drift into immobilizing grief. She explored the lure of personal euthanasia, finding comfort in obtaining the means for it, yet was held back by downsides she imagined: the horror of the person who would come upon her corpse and the idea that the taking of her own life would define her.
"It worries me, for instance, that my death certificate would read 'suicide' as a cause of death, with everything that the term implies these days: mental angst, hopelessness, weakness, the lingering whiff of criminality – a far cry from, say, the Japanese tradition of seppuku, or suicide for honour's sake. The fact that cancer was actually my killer would be lost to posterity, as would the fact that I am not, by any fair measure, mad."
Indigo Carmine, a dye used by urologists, became unavailable sometime last year until we got it back on our shelves recently, as Bruce Angel (Urology Nursing Service Lead) informed me. A note he forwarded me from the OR pharmacies explained that the price has gone up from $3.00 per ampule to $123.45. Indigo Carmine (indigotindisulfonate sodium) solution was once used to in testing renal function, but now is mainly used to find ureteral orifices during cystoscopy. An intravenous injection of 5 ml (40 mg) appears in urine within 10 minutes.
Indigo is a natural dye extracted from certain plant leaves, most commonly the tropic genus Indigofera, that also has analgesic and anti-inflammatory properties. It is one of the less common natural colors and has an ancient record. Junius Bird (1907-1982), an American archeologist born in Rye, New York, and a possible inspiration for the fictional Indiana Jones, excavated a prehistoric settlement in Peru in the 1940's that yielded the earliest evidence for human use of indigo dye.
Sunshine on a cloudy day. When Smokey Robinson, in 1964, penned the lyric "I've got sunshine on a cloudy day and when it's cold outside I've got the month of May," he identified sunshine and May with the sweetest things in life. His inspiration, "my girl" of the song, was his wife Claudette and fellow Miracles band member. [Above: 1965 album; below Claudette Rogers Robinson, March 12, 2013 at star for the Miracles in Hollywood. Wikipedia.] I saw Smokey on a plane a few years back and he was still a magnetic presence, 50 years after that enduring song. May is a busy time for most people, but it's an optimal time to restock and recharge the sweet memory bank with sights, sounds, and experiences of Spring.
Whether tomorrow brings sun or clouds, the greatest 2 minutes in sports, The Kentucky Derby, will bring its own form of sunshine for the crowd, the champion, and those who pick the trifecta. This will be the 144th race, although the trifecta only goes back to the 1970's when the betting opportunity of picking first and second place finishers in order expanded to the first three. Smokey's trifecta seems to have been Claudette, sunshine, and May.
More shades of blue. Azure, as a color name traces back to the days of heraldry, deriving from the deep blue stone, lapis lazuli. A lighter blue, bleu celeste, more closely mimics the sky. Royal blue, darker than azure, dates back to a dress made for Queen Charlotte, consort of King George III. Driving down Washtenaw Avenue in May, east of the campus, you will see many blues splashed on "The Rock." These colors come from real buckets of paint, rather than tidy computer color wheels and display the exhilaration of school kids anticipating the end of school and the freedom of summer or the intoxication of graduation. Some people driving by this object to the messiness, but most of us take pleasure in the exuberant freedom its colors reflect, with the schoolkids as stand-ins for the rest of us.
[Above: The Rock.]
[Above: refracted May sunlight on carpet. Below: color wheel from Wikipedia.]
Jill Macoska, Nesbit faculty alumna and currently the Alton J. Brann Endowed Distinguished Professor in Science and Mathematics and Cancer Biology at University of Massachusetts in Boston, was just back in Ann Arbor for the graduation of her daughter Nicole. Jill wrote last month to identify those tiny blue flowers mentioned here last month. "Good morning, David – Those tiny blue flowers are called 'squill'; they and snowdrops are usually the first bulbs to poke their heads up out of the snow in spring! Boston has been a good fit for the Macoska family. Nicole came back to UM for a double major in Political Science and Communications (Below: Class of 2018, high distinction, Phi Beta Kappa.).
Jill wondered how many new UM alumni children and grandchildren came from the Urology Family.
Department chairs no longer sign Medical School diplomas individually by hand. I miss the scheduled sessions when we took our turns signing upwards of 200 certificates (extras, because a few inevitably get messed up). It might be viewed as a waste of time, but for me it was a reflective ceremonial interlude. A sweet "hard-stop" in the busy cycle of academic medicine, the signing reminded me that we are here in our roles at Michigan for very consequential reasons. Below you see Dr. Valerie Opipari, Chair of Pediatrics, a few years back with the azure seal of the maize and blue up close.
Posted in Academia, Academic medical center, Colors, Graduate medical education, Health care, Maize and Blue, May, Medical education, Medical humanities, Nesbit Alumni Society, Spring, University of Michigan Health System
Spring and all
DAB What's New Apr 6, 2018
Spring and All is a collection of work in the early writing career of William Carlos Williams, a New Jersey general practitioner in the first half of the past century. The slim volume is an odd collection of alternating prose and free verse, best known for a poem that begins, "By the road to the contagious hospital…" A recent edition of the work includes an introduction by CD Wright with a phrase comparing Williams to an earlier poet from New Jersey, Walt Whitman. "Like Whitman, he [Williams] would gradually come to a great human understanding, an apprehension that eluded most of his peers." [Spring and All. WC Williams. New Directions Book, 2011.]
Published in 1923, Spring and All came during a time that strained human understanding, juxtaposed between WWI and the Influenza Epidemic that preceded it, and the Great Depression a decade later. Only one year before Spring and All, TS Eliot published The Waste Land, a more obscure and academic poem with complex literary references and snippets of multiple languages. The landscape that Williams presents is not quite so bleak, nor is April (spring) quite so cruel. Still, the Williams terrain is far short of a Disneyland, although some promise is held out as "sluggish dazed spring approaches…" Williams embraced the season cautiously, feeling perhaps some recovery from the recent devastations of war and epidemic, thankfully unaware of the impending economic catastrophe that ran from 1929 through most of the 1930s. In much of the work Williams conveys an ominous sense of mankind's tendency toward self-destruction. [Above: by the path to the Frankel Cardiovascular Center; below, Williams, Wikipedia.]
Whatever constraints the world may bring to bear, spring is generally a season of optimism and refreshment. After a rough winter in much of the northern hemisphere including North America, Europe, Russia, Japan, and Korea, we are glad for spring and all it brings.
[Above: Signs of spring at home, early daffodil and tiny blue flowers sprouting with a few flecks of overnight snow. April, 1, 2018.]
We pursue that idea of a "great human understanding" in the practice of medicine, an understanding never fully realized, but one that grows even as challenged by the practicalities of each day and the idiosyncrasies of each patient. Physicians "take histories" and examine evidence in pursuit of authentic narratives that allow them to understand the conditions and needs of their patients.
Using the phrase, the practice of medicine, the final word medicine seems increasingly parochial and archaic. In this era of specialty healthcare, "the team" has supplanted the solo practitioner and the term medicine, implies a drug or a specific branch of learning and practice itself more than encompassing all of healthcare. Reference to the practice of medicine is parochial in that it excludes other essential practitioners or binds them up within the terminology of my branch of healthcare.
Yet, the practice of medicine has a comforting ring to it, recalling Hippocratic times when the practitioner's responsibilities were outlined in a sacred oath and the profession of medicine was as much art as science (observation and reasoning). The historic sense of the professional calling of a doctor tending to a patient worked well up through much of the last century, exemplified by horse and buggy house calls, Norman Rockwell's depictions, Albert Schweitzer's humanitarian work, and Marcus Welby's television dramatizations. The one-on-one relationship of a practitioner to a patient is still essential to excellent healthcare and it is a relationship that offers magical moments for greater human understanding. The dilemma in modern healthcare is that this special duality must find a place within the great tent of the team.
These last thoughts beg a big question – do our students and successors understand the earlier eras of healthcare that today's healthcare is predicated upon? Do they know who Hippocrates, Galen, Avicenna, and Lister were, or what they achieved? Do our students know of Norman Rockwell, Albert Schweitzer, or Marcus Welby? Should they know these things and how would they know of them? Today's medical education, indeed all of healthcare education, falls short of the mark in teaching the history and context of healthcare. To some degree this should have been the job of higher education (we used to call it liberal education), but the need in medical school and residency education is even more acute. Without history and context, it's hard to find values that are so essential to human understanding.
Morel quandaries. Spring is morel time in Michigan. These wild and mysterious mushrooms defy all human efforts to cultivate and industrialize them. Experienced mushroom hunters, such as our friend and neighbor Mike Hommel, are skilled at finding and accurately identifying morels, and there are few things better on the palate than the end result of his searches.
[Above & below: morels]
Mushrooms, although not morels, play a pivotal role in the current film, Phantom Thread, but no more should be said for those who have yet to see this strangely elegant period piece and psycho-drama.
The morel (genus Morchella) evolved from a yeast only as recently as 20,000 years ago, according to some authorities, although others claim it is an ancient cup fungus as old as 129 million years (at this point, science has only deepened the mystery). Many morel species exist, perhaps 60, having distinctive and highly polymorphic honeycomb configuration allowing effective camouflage as pine cones. Morels have some relationship to recent fires and decaying fruit trees, but the exact formula of conditions for them to prosper remains elusive. The morel supports a multimillion dollar industry business of hunting and gathering. Had William Carlos Williams ever experienced morels, they surely would have figured in his Spring and All landscape: "Beyond, the waste of broad, muddy fields brown with dried weeds, standing and fallen patches of standing water the scattering of tall trees…" Morels are of some spring's mysterious marginalia, happy little surprises of the season and all.
Daily practicalities confront and confound everyone, navigating their lives and work, and physicians do not get a free pass from them. In the horse and buggy era, a house call was no easy matter, given the inertia to leave a comfortable home at inconvenient moments, saddle up horse and a buggy, and then set off to the patient's home. Electronic medical records among many other systemic constraints offer newer barriers to many practitioners today, and even those facile with keyboard medicine find they have traded spontaneous interactions with patients for new formulaic work flows of check lists, drop down menus, smart sets, and the lure of cutting and pasting.
Patients as well as healthcare providers must also deal with modern daily practicalities that are impracticalities, more often than not. Matters of finding time from work, transportation, parking, insurance forms, questioning at front desks, forms to fill out, and the incessant repetition of one's story to an array of healthcare workers dampens the spirit of the human soul. Yet, an ultimate audience with a single healthcare provider (I use this more inclusive term because there are a number of categories of us) is usually a moment of immeasurable importance for patients, who are hopeful for someone to listen carefully to their narratives and gain an authentic understanding of their stories, their histories, instead of processing them into checklists and pre-written sentences and dot-phrases.
Williams began Spring and All with an admission of mixed optimism and inadequacy as a writer:
"If anything of moment results – so much the better. And so much the more likely will it be that no one will want to see it."
Writers are vulnerable to mistakes and criticism of their work (criticism of themselves as people!) comes with the territory. Writers must accept that they will make mistakes and that some readers in their audience will find their work erroneous in parts or lacking in other ways. It may sting when errors are discovered, but that is a good thing in that correction (peer review, if you will) makes the product better and sharpens the writer's own fact-checking and proof-reading going forward.
Criticism of style, argument, or quality of thought is a more painful challenge. Good criticism can sharpen an author, although some criticism will be wrong, misdirected, or even malicious. A writer has to hear it all, in the hope of learning and fine-tuning the craft of thinking and writing. Williams, in his writings, put himself "out there" for the world to inspect, criticize, fault, or praise. Some factor in his psyche compelled this expression of art, a factor closely tied to the art of his medical practice.
Spring and All is a quirky and complex collection of prose and poetry. Williams was around 40 years old when this was published and no sensitive novice. Yet he opened the work by admitting that he was not fully up to the task of appreciating and expressing that "great human understanding." Furthermore, he revealed his vulnerability to criticism.
"There is a constant barrier between the reader and his consciousness of immediate contact with the world. If there is an ocean it is here. Or rather, the whole world is between: Yesterday, Tomorrow, Europe, Asia, Africa, – all things removed and impossible, the tower of the church at Seville, the Parthenon.
What do they mean when they say: 'I do not like your poems; you have no faith whatsoever. You seem never to have suffered nor, in fact, to have felt anything very deeply…'"
Williams, like other physician-writers, double dip into the conundrum of human understanding in that they are simultaneously medical practitioners and writers, allowing each craft to fuel the other. It is astonishing that we don't embrace the study of major physician-writers like Williams during medical training with the rigor that we rightly insist upon for other relevant topics such as genetics and pharmacology.
Hall of corrections. Last month I did a disservice to John Hall (Nesbit 1970), misattributing his practice to the Traverse City area, when in fact he worked in Petoskey. Ward Gillett (Nesbit 1985) set me straight. On the other hand, Tom Hall (Cleveland Clinic), who passed away in 2002 practiced urology in Traverse City, and Bob Hall (Wayne State University) also practiced urology in Traverse City. None of these urologists is directly related, although they and I and you are all cousins, according to a quirky book, It's All Relative, by AJ Jacobs, who writes that all humans go back in time 8,000 great grandparents ago to a common pair of human ancestors who "hunted, gathered, and vigorously reproduced on the plains of Africa about 200,000 years ago." [AJ Jacobs It's All Relative, Simon & Shuster, 2017. P. xi.]
John Hall trained here at the University of Michigan exactly at the mid-point in our urology centenary and reminds me that he is thus the "fulcrum" of the Michigan Urology story. Knowledge and technology changed urology over the course of its century, but our mission and values have been constant and will likely remain so in the next iteration of departmental leadership.
Blind eye. On an April day in 1801, a few days earlier in the month than today, the Battle of Copenhagen launched an enduring metaphor. The phrase of turning a blind eye is attributed to Admiral Horatio Nelson, of the British Royal Navy who had been blinded in one eye earlier in his career. The story goes that during the April Battle in 1801 his superior admiral, the cautious Sir Hyde Parker in charge of the overall battle and sensing defeat, signaled Nelson's forces to discontinue their action. Nelson was a subordinate but more aggressive admiral and when told of the signal flag message, lifted a telescope to his blind eye and claimed that he did not see an order to desist. [Above: Nicholas Pocock, The Battle of Copenhagen, 2 April 1801, Wikipedia.]
The metaphor took on a life of its own and today would come to be called a meme – an idea, image, or behavior that spreads in a biologic fashion like a gene, replicating and modifying itself within and across cultures and times. The meme neologism is a contribution of Richard Dawkins, worth discussing at a later time.
Blind Eye is the title of a book by James Stewart, an investigation of the true story of a young physician who, for likely psychopathic reasons, poisoned or otherwise killed hundreds of patients and others until apprehended by the FBI. The title comes from the educators in academic medicine who turned blind eyes to his aberrant behavior. That story closely mirrors an earlier true story of a physician, involving Michigan Medical School graduate Edward Mudgett of the class of 1884, who went to Chicago after getting his MD, changed his name to HH Holmes and similarly dispatched scores of people for personal gain or oddly-derived pleasure. Eric Larson told that story in bestselling book, Devil in White City. I read both cautionary tales during a dark interlude in our own Michigan Urology story 20 years ago. Since Admiral Nelson, the phrase has become ubiquitous in English, you can hear it used early in the film, Black Panther.
Certainties in life, April 15 for example. The author of the phrase claiming only two things are certain in life may never be known, but this is an obvious and nearly universal belief, cynical as it is. Most of us can't seem to get around taxes, this month most particularly, and none of us will avoid the other absolute. Mortality always trumps economics.
It's easier to confront economic issues than the mortal one and for an economist, life is viewed from the perspective of supply and demand tensions and balance sheets. Everything else, outside the economic issues, is a matter of "externalities." The problem with economic models is that most of what really matters to people in the real world is reduced to those externalities. One can argue that Adam Smith's book, An Inquiry into the Nature and Causes of the Wealth of Nations, suggested that economic wealth derived from all the externalities of the people, social groups, and markets working together. Economic wealth cannot be isolated from the externalities that create it.
Wealth of Nations was published in 1776, but Smith's more astonishing book, The Theory of Moral Sentiments, came earlier in his career, in 1759 when he was only 36 years old. Permit a repetition here of the signature thought from that work.
"Howsoever selfish man may be supposed, there are evidently some principles in his nature, which interest him in the fortune of others, and render their happiness necessary to him, though he derives nothing from it except the pleasure of seeing it."
Smith's belief in mankind's better nature preceded and likely superseded his ideas about the wealth of nations and the human economic model that today would be described as homo economicus, wherein human choices are primarily those of self-interest in daily life and in commercial markets, as he justifies in the following quote from the 1776 book.
"It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest. We address ourselves, not to their humanity but to their self-love, and never talk to them of our necessities but of their advantage."
Differing ideologies can exist harmoniously in the head of one person because human life is complex and not reduced to simple models. Its daily practicalities demand both functioning markets of commerce, where self-interest can rule the day if rules and opportunities are fair, existing on a bed of humanity anchored by kindness, kinship, and other characteristics of human civilization that have defined our species and allowed it to grow.
Spring, now and then. Emerging from a challenging winter, spring brings welcome change. When the general practitioner from Patterson, New Jersey published his collection in 1923, the specialties of medicine, the specialties of all of healthcare, were just starting to express themselves. Simultaneously serving as Dean of the Medical School, Professor and Chief of Surgery, and the University of Michigan urologist, Hugh Cabot was building a 1000 bed university hospital that would define the emerging medical specialties and initiate a urology residency training program that would come into fruition three years later with Charles Huggins and Reed Nesbit as Michigan's first urology trainees.
After Cabot was fired by the Regents in 1930, Nesbit expanded the training program and would train 77 individuals including Jack Lapides who trained an additional 64. McGuire continued the process, for another 42 residents and fellows. Intervals of Bart Grossman and Joe Oesterling followed with another 8 and 16 trainees. Jim Montie, who led Michigan Urology to departmental status, trained 47 and with our graduation this spring 41 residents and 34 fellows will have been trained here under the present era of leadership, at last count. At this point I don't know if Cabot trained any others besides Reed Nesbit and Charles Huggins, so the count of Michigan urology trainees stands at 329 to date.
This July a new set of residents and fellows will continue the traditional of urology education in Ann Arbor. The residents will be: Kathryn Marchetti of the University of Michigan, Kyle Johnson from University of South Carolina, Javier Santiago from Baylor Medical School, and Roberto Navarrete from Wake Forest School of Medicine. Our new fellows will be: Guilia Lane from University of Minnesota (FPMRS) and Jeffrey Tosoian from Johns Hopkins Hospital (SUO).
Our new residents will complete their program in 2023, a full century after the spring of William Carlos Williams. They will continue a path of medical service that began well before Hippocrates. In their own careers and in their own unique fashions they will follow William Carlos Williams in search of a greater human understanding to alleviate illness and suffering. Evolving therapeutic tools, as attractive and incredible as they are, will always be secondary to the human understanding that deploys or restrains them. We hope to inspire the class of 2023 and our fellows to grow their capacities for human understanding just as they grow their knowledge and skills throughout their careers. That understanding will never be complete, but it can grow experientially, patient-by-patient, and humanely without being co-opted by the formulaic encounters of electronic medical record and artificial intelligence systems.
Art Can Help is the name of a short book I recently found in Washington, DC, at the National Gallery of Art. With summer and our annual Chang Lecture on Art and Medicine (Thursday, July 19) soon ahead, I couldn't resist the purchase. The author, Robert Adams, is a well-respected photographer and a superb writer and critic (photo below, Wikipedia). Coincidentally, like Williams, he came from New Jersey. This little volume is a series of short essays on a number of photographs, but is introduced by comments on two familiar Edward Hopper paintings. The title is provocative – help what, help how? Clearly the answer is up to the reader, but as I processed the book, it seemed that Adams intended to show how art (visual art, in this case) brings us closer to that great human understanding. It is a book I'll return to, adding more and more marginalia and end-page references. [Art Can Help. Yale University Press, 2017.]
Let me close this monthly essay with two passages from Adams, reproduced with his permission.
"Edward Hopper's Early Sunday Morning is a picture upon which to depend. It is affirmative but does not promise happiness. It is calm but acknowledges our failures. It is beautiful but refers to beauty beyond our making."
These four sentences offer an astonishing take on a well-known image, offering the ideas of depending on a picture, finding affirmation and calmness, the slightly buried idea of truth (not promising happiness, acknowledging failures), and the concept of beauty. Adams reminded me of a line in Spring and All by Williams: "so much depends upon a red wheel barrow."
Toward the end of the book Adams inspects work by American photographer Anthony Hernandez, invokes the name of another great photographer from an earlier era, and affirms the importance of our choice to care:
"Alfred Stieglitz said that 'all true things are equal to one another', and in that he spoke for most artists. They are convinced, despite having to sort through daily practicalities by triage, that everything is of immeasurable consequence…
For Anthony Hernandez, everything really means everything – a chair made of broken drywall, a fishing place where one might not want to eat the catch, a platinum-colored wig, … and everything means everyone – a woman with flowers in her hair, a man with a boxer's broken face, an officer worker alone at noon with a book…
Why on the evidence of pictures is everything important?
First, because we are part of it all … our part being to be blessed with language that enables us to stand outside ourselves and make choices. We can choose to be caring."
[Window box, Tradd Street, Charleston, SC.]
Thanks for reading Matula Thoughts this April, 2018.
David A. Bloom, University of Michigan, Department of Urology, Ann Arbor
Posted in Academic medical center, Art, Graduate medical education, Health care, Medical education, Medical humanities, Nesbit Alumni Society, Spring, University of Michigan, University of Michigan Health System, William Carlos Williams
DAB What's New Mar 2, 2018
Marginalia of sorts
Marginalia. As a young reader I recall making casual sideline notations in margins of my books and, in time, detailed marginalia, underlining, and highlighting expanded into my college and medical school textbooks. Later, during residency I heavily personalized my pages of Campbell's Urology trying to digest them intellectually.
The habit persists and marginal notes help make sense of what I read and leave reference points to which I can easily return. Other reading has replaced textbooks my marginalia drifted to and consolidated on end pages, creating personalized indices of page references and related comments (below "end-page marginalia" in Harari's Sapiens).
Marginalia-making has been a human habit ever since books existed with numerous famous examples as early as amusing marginal drawings by monastic scribes alongside their serious transcriptions. A notable marginal comment unsettled the world of mathematics for nearly four centuries after French lawyer Pierre Fermat wrote in the margin of a book he was reading in 1637 that he had solved a puzzling mathematical conjecture, but claimed his solution was too large to fit the margin.
The book was a 1621 edition of Arithmetica by 3rd century mathematician Diophantus and its actual margin looks generous by my standards, although I am no mathematician. [Above: Wikipedia, public domain.] It may never be known if Fermat's solution was correct or if he was joking, although he didn't seem much of a jokester and his other mathematical work was accurate. Furthermore, his unsubstantiated comment was taken so seriously that it was included in later editions of Arithmetica (below: Wikipedia).
Many others tried and failed to solve Fermat's Conjecture over the next three centuries until 1994 when British mathematician, Andrew Wiles, came up with the answer.
Scribbling in the margins of library books or books of your friends is bad form, but marginalia in personal materials conveniently identify meaningful passages or record pertinent or tangential thoughts. Some mental process pauses readers from reading long enough to acknowledge the adjacent text in some way. Marginalia are evidence of our effort to find meaning in the things we encounter.
Electronic books allow similar personalizations, although it's not quite the same, in part because electronic screens lack the comforting tactile sense of paper. Electronic formats, however, offer new opportunities and challenges for marginalia: private marginalia can become public, aggregated, and analyzed. Audio books allow listening as we close our eyes or move physically through life, but as much as I like audio books when driving, the opportunity to make marginal notes is problematic and any spontaneous thoughts I have when hearing certain passages are usually gone from memory by the time I've reached my destination.
The compulsion to annotate or otherwise leave personal evidence of one's presence or thought pre-existed books and is widely exercised on other cultural artifacts and the environment-at-large. Cave paintings, rock carvings, initials on tree trunks, furniture inscriptions, children's heights on door frames, and urban graffiti are footnotes of ourselves and plant notice of us for the future. The cliché George Washington Slept Here was a 1942 play and film about a couple who moved into a run-down farmhouse (because of their dog) and they discover the first president actually stayed there during the Revolution.
The top of this posting shows a section of the Berlin Wall that faced the free part of the city, while below you see the unmarked reverse side that faced the Soviet side. These sections are on display in Washington, DC at the Newseum and were salvaged after the wall came down in 1989. The contrast is stark.
Urban graffiti, as annoying and vulgar as it can be, are an expression of personal freedom and the 45 words of the First Amendment that represents a core belief of our representational democracy.
A video display at the Newseum displays interviews on a random street showing that people are far more likely to be able to identify all the members of Homer Simpson's cartoon family than to know the five freedoms of the First Amendment (religion, speech, press, assembly, and petition of the government). The video references national surveys that support this unfortunate observation showing 20% of Americans can recall all Simpsons, whereas only 3% know all five freedoms.
The marginalia habit fills the strong human compulsion to seek relevance and meaning, a need played out in many ways including early forms of social media content; "Kilroy was here," "George loves Tina," and their equivalents have been expressed by our species since the earliest human days. Graffiti as urban social marginalia, occasionally becomes valued public art such as the works of anonymous British artist known as Banksy. [Below: a Banksy image from Wikipedia.]
Historical plaques and other public commemorations are structural marginalia, we mentioned those of the old Ann Arbor Bus Station, last month, on the Residence Inn in downtown Ann Arbor. Historical markers are marginalia of place. You can find plaques at the Michigan Union on the top front landing step and on the building wall commemorating the first occasion that John F. Kennedy publically articulated the Peace Corps idea. It was during a campaign speech October 14, 1960 at around 2 AM, a remarkable time for a presidential campaign speech that highlighted the vigor of the young presidential candidate. Arriving from New York in those early hours he went directly to the steps of the Union where a crowd of around 5000 students was waiting on State Street. Kennedy began his remarks by describing himself as "a graduate of the Michigan of the East, Harvard University." He spoke about the importance of public service, asking for young doctors and engineers, as an example, to spend a period of time in Ghana or other places. You can find the speech on YouTube and he concluded:
"I come here tonight to go to bed, but I also come here tonight to ask you to join in the effort! This university – this is the longest short speech I've ever made and therefore I'll finish it. Let me just say in conclusion that this university is not maintained by its alumni or by the state merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose and I'm sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign, I come here asking for your support for this country in the next decade."
It was an inspiring speech. As an aside, the official portrait of Kennedy (above: painted by Aaron Shikler, whom Jackie Kennedy selected after the assassination) is on display at the Smithsonian National Portrait Gallery, along with all presidents up through Barack Obama (recently unveiled). The Kennedy portrait is the only image of a president looking down and away from the viewer, that having been Jackie's choice.
Kennedy's idea continues to tap into a compulsion for relevance and meaning that many students and others feel so acutely. The Peace Corps, finalized in law in the first months of his presidency, continues to resonate with college students across America. Since 1961 Michigan has been among the top four contributors to the Peace Corps with 2720 students volunteering since 1961 (after Berkeley, Madison, and Washington. [Mandira Banerjee. Feb 21, 2018. The University Record.]
Eleven years ago today, 2 March 2007, was the second day of my time as chair. Going to my computer I found digital images from that time in our department, including this early picture (above) of the board in my office. This has served as my functional marginalia for the Department of Urology for the past 11 years. Faculty are in the boxes on the sides and activities, units, and projects in the middle. The board changed over the years as we grew and became more complex. The picture below shows one of our visits to the billing center in the KMS Building south of I 94. Jack Cichon (now retired) was our stalwart Chief Department Administrator (CDA) and Malissa Eversole was then his understudy, having since then come into her own as our current CDA.
Below you see Ed McGuire in the center with 2 of his former fellows (now faculty) on the left (Anne Pelletier-Cameron and Quentin Clemens) plus Stu Wolf (faculty) and Walter Parker (resident) on the right.
Since 2007 the changes in healthcare education, research, and clinical delivery have been head spinning. Today the UM Medical School and health care system is rebranded as Michigan Medicine.
The time has flown by, in my mind, and if this present interval of stewardship of the Department of Urology is deemed successful in any measure, the success is due overwhelmingly to our faculty, our residents, our nurses, our physician assistants, our researchers, and our staff. Sister departments in the Medical School and this great University also account for our success; we flower in fertile soil.
This success should continue to grow with our next departmental leader whom I hope will help our clinical divisions and team do their jobs optimally, as I have tried to do. We want to avoid a repetition of the darker events of the 1990's (as duly recorded in the Wall Street Journal and the Detroit Free Press), when Ed McGuire's successful term and Bart Grossman's interim stewardship were interrupted by a few difficult years until Jim Montie's leadership brought us into departmental status and initiated the Dow Health Services Research Division. [Below: Khaled Hafez, Hugh Solomon, Jim Montie.]
March brings Spring steelhead to mind. It's been many years since I've been on the Pere Marquette River thigh deep in waders feeling the rush of icy water working its way toward Lake Michigan. Migrating steelhead salmon, pressing retrograde to reconcile with their past, have few things on their minds at that stage and feeding is not high in their priorities. Lures need not be very sophisticated or authentic, as the fish are on their migration to spawn so they are as likely to bite out of anger or random habit than culinary urge. [Above: Brent Hollenbeck and steelhead. Photo credit: Jeff Montgomery.]
Steelhead rainbow trout (Oncorhynchus mykiss) hatch in inland streams and then swim downstream to forage in the Great Lakes (or the ocean, on the west coast) for 2-3 years. Winter-run steelhead are sexually mature and generally have a shorter run to their spawning grounds, whereas the summer-run steelhead are sexually immature when they leave the lakes or ocean and travel deeper inland. Actual spawning for either type happens in late winter or spring. These Pacific rainbow trout were introduced as immigrants from California to the Au Sable river around 1876 and after many generations are well established residents although state-managed hatchery programs supplement the existing wild fish.
Steelhead provide a loose metaphor for medical professionalism. We train our successors in the streams of academic medical centers and on maturity they go off to do their thing in the wide world. Toward the end of their careers many of them want to reconcile with their origins and travel back upstream to check out their starting points. Forgive me for stretching this analogy, but I do want to put in a plug for our Nesbit alumni, former students, and friends of the department to come back for one of our academic events, particularly in the next two years as we gear up to celebrate the Centennial of Urology at Michigan in 2019-2020.
Fish and urologists. Fish have twofold purposes. Primarily they pass along their DNA to their successors and secondarily they serve the larger planetary ecosystem. The optimal life span of a steelhead allows 4-6 years for one or more foraging careers in the wide world, although some Pacific steelhead live as long as 11 years and grow to 55 pounds and 45 inches, according to the National Oceanic and Atmospheric Administration (NOAA) Fisheries website.
Medical professionals have a fundamental purpose of caring for their fellow creatures, motivated by genetically crafted mirror-imaging that produced the essential human phenotypes of kindness and empathy. Secondarily, healthcare people serve their ecosystem by educating their successors and expanding the armamentarium of knowledge and technology. The career of a urologist is 40 years, give or take a decade, foraging in the real world of clinical medicine. While steelhead must adapt to gradual warming of the oceans, urologists need to adapt to rapid changes in knowledge, technology, and regulatory matters. Technology and market forces are driving changes in urologic practice at least as much as scientific evidence, leaving practitioners and patients sometimes uncertain of what treatment fits best.
Urologists are skilled in techniques and technology to solve urological problems but, no less than any other physicians, urologists also offer their personalities, opinions, and reassurances to patients throughout interactions that are bundled under the unfortunate label "encounters" in today's workplaces and medical records. The language and demeanor experienced by patients often are just as meaningful to them as any treatment or technology. Indeed, the non-technical aspects of the encounter may impact the patient more than any specific medical service. This is a prime difference between the professional and a commodity natures of health care. People, as patients, treasure the right human touch.
The essential deliverable of our department is kind and excellent patient care, thoroughly integrated with education and innovation at all levels. This is not just our priority, but the priority of Michigan Medicine. Below is another picture I found from 2007 showing a faculty member and two residents who exemplified that essential deliverable back then and do so today in their new locations: Gary Faerber, now at the University of Utah; Emilie Johnson, faculty at Lurie Children's Hospital and Northwestern Medical School; and Kathy Kiernan on the right, faculty at the University of Washington and its children's hospital.
The human touch is also conveyed by words. A recent Viewpoint in JAMA by Arthur Barsky of the Department of Psychiatry at Brigham and Women's Hospital is worth reading. [Barsky. JAMA. 318:2425, 2017]. The title sums it up: The iatrogenic potential of the physician's words. Barsky invokes viscerosomatic amplification to explain how a physician can affect through words and attitude. (As is usual on these pages, we use physician as a synonym for healthcare provider.) Techniques and technology are unquestionably at the core of urologic practice, but the art of clinical practice is far more than its tools and treatments. Kindness, words, and professional touch are no less essential.
Expectation. Human brains add further dimensions to medical treatments, with the matter of expectation. Every treatment carries the possibilities of real benefit or harm, but another two-edged sword exists in our capacity for imagination, something we cannot easily turn off. We may readily imagine benefit even when no physical or physiologic benefit can be explained (the placebo effect) or we may imagine elements of harm (nocebo).
Placebo and nocebo effects confound medical treatments when a therapy (legitimate or bogus, scientifically-validated or apocryphal) has a more positive or more negative effect than it rationally should have. This reflects changes in psychobiology rather than changes in physiology, pharmacokinetics, or other factors that are directly measurable or attributable to the treatment.
Nocebo, the evil twin to the placebo, is a term coined in 1961 by WP Kennedy. [Kennedy WP. Med World. 1961; 95:203, 2013.] The evil twin metaphor came from Michael Glick in an editorial in the Journal of the American Dental Association. [Glick M. Placebo and its evil twin, nocebo. JADA.2016; 147:227.] The nocebo effect occurs when negative expectation of therapy exacerbates the negative effect that the treatment rationally would cause. For some patients a given therapy, let's say a radical prostatectomy, in addition to successfully removing a malignancy (from which direct harm might have been years away) with minimal detriment to related anatomic structures, might produce a sense of relief that carries with it additional placebo effect. For other patients a nocebo effect negatively magnifies the overall therapeutic experience and collateral damage of any attendant detriments. Every patient responds individually and idiosyncratically to an expectation and to a treatment. These phenomena, placebo and nocebo, should be anticipated for almost everything we offer in healthcare, and to the extent that we understand these possibilities and prepare patients and their families for them, we will improve the patient experience. This is one of the myriad ways that complex health care cannot be easily managed as a commodity or by artificial intelligence.
As scientific medicine emerged in the 19th century it consolidated into subspecialty medicine in the 20th century and anatomic, physiologic, and microbial determinants became the focal points of healthcare. Cognitive and social factors were "marginalia" of most patient encounters. Now, in the 21st century it is clear that cognitive and social factors are equally important parts of everyone's healthcare needs. Our profession and its business are no longer accurately described as the matter of "medical care", but rather the matter of health care.
A prescription for a treatment or an operative procedure may be based upon symptoms and observations as entered into checklists and databases. Emotional responses and social determinants are not so easily factored in electronic medical records, particularly within the constraints of time-constrained encounters. Watson and other artificial intelligence systems are working their way into examining rooms, bedsides, and operating theaters, but these are not as effective in sensing the co-morbidities, social determinants, and other "marginalia" of the human condition, as is an attentive and kind human being. Artificial intelligence engenders great enthusiasm, but humanity should never surrender its ultimate agency to algorithms created by a self-empowered cadre of programmers.
Considering gaps last month, including astronomical gaps, calendar gaps, and geological gaps, we saved an important one to mention now. A gender gap has long been present in the field of urology, although Michigan more than most other training programs began to change that imbalance, starting with Carol Bennett, who trained under Jack Lapides and was Michigan urology's first woman graduate. Carol is now on the faculty at UCLA. In her era of training women in urology were rare. Today the situation is quite different and at Michigan we have had residency classes where women outnumber men three to one. Other years we have returned to 100% men and some year soon we could as easily have all women. In our selection process, we don't aim for an optical effect, but rather try to pick the best talents and fits for our department from the yearly applicant cohort. Ultimately, individuals from the candidate pool make their selections when they rank the programs. [Below: Peter Knapp, Nesbit 1985 and Carol Bennett, Nesbit 1983.]
Women graduates from the University of Michigan Medical School and women trainees from our urology training program (all are considered Nesbit Alumni) are making significant impact in the world of urology, academically and in the private sector. Below you see a dinner at the recent annual meeting of the Society of Women in Urology. From the left: Cara Cimmino UMMS and faculty at Emory, Priyanka Gupta UM urology faculty, Allison (Lake) Christie Nesbit graduate and urologist in Tennessee, Miriam Hadj-Moussa Nesbit graduate and UM urology faculty, Lindsey Herrel Nesbit graduate and UM urology faculty, Akanksha Mehta faculty at Emory, Amy Luckenbaugh UM resident, and Annie Darves-Bornoz resident at Vanderbilt.)
John Hall, Nesbit Alumnus 1970, wrote recently and gave me permission to give his note wider distribution here in Matula Thoughts. I came to know John after I came to Ann Arbor, largely through his high-quality practice, a sliver of which I appreciated through his pediatric referrals, as well as his local care of people I knew in the Traverse City area where he worked. Letters like his are one of the great pleasures of mine with What's New our monthly email and it's sibling Matula Thoughts, the web version. As we get closer to our Centennial and to reformulating our departmental history, his recollections, and perhaps yours as well, will be important to us.
From John:
"Hi Dave, I was just reading your letter of December 21, 2017. It made me think of the 5-6 doctors who staffed Urology during my training. Your staff will be limited to how many names you can put in the letterhead margin. It's like how many doctors can fit on the head of a pin.
I finished my training in 1970, Urology 50. By 2020, Urology 100, if I'm still kicking I will be one of the few to span the history of the department. I started my contact with Urology as a student and served as a "nurse" in the Urology dialysis center. I took the vitals as the residents stirred new electrolytes into the Kolff Twin Coil Baths. As a result, I knew many of the residents from the fifties and sixties. Also, since I was appointed to residency by Dr. Nesbit, I met many of his trainees who now directed new urology departments, when they returned to AA [as visiting professors or guests], I also once met Dr. Huggins.
Dr. Nesbit retired in 1967, six months into my residency. So my group became Lapides 1. I'm not going to measure up to your knowledge of urologic history, but I am willing to provide my perspective of Michigan Urology to the Centennial Committee. Please let me know if I could provide some value to the process. Please keep writing Matula Thoughts, the highlight of my month! … John."
Thank you, John and yes, please continue your perspectives! Much is contained in John's brief note: the idea of 100 years of urology in AA, the imprinting of students, the Kolff "artificial kidney", Nesbit alum and Nobel Prize winner Charles Huggins, and the long list of chairmen Nesbit trained. Overstated only is the disproportion of historical knowledge between me and John – he knows vastly more about that midpoint in Michigan's urologic story and I hope we can get as much as possible in print for you and others to understand our perspectives.
Since that note, John sent me a copy of his book "I'd Rather Be Sailing" and I expect to go through it and decorate it thoroughly with my own marginalia. As we reconstruct the 100-year story of Michigan Urology it will be the personal marginalia of alumni such as John Hall that provide the context, color, and personalities to illuminate the names and dates of our narrative.
With a few weeks until Spring, 2018, best wishes from David Bloom and Michigan Urology.
Posted in Academic medical center, Fish, Graduate medical education, Health care, History, Medical education, Medical humanities, Nesbit Alumni Society, University of Michigan, University of Michigan Health System, Winter
DAB What's New Dec 1, 2017
The Michigan Theater, seen above on a crisp autumn evening, is one of Ann Arbor's many delights, making it easy to "sell" our town to medical students who interview for urology residency. Reflecting the halcyon days of motion picture palaces, the theater opened January 5, 1928 with grand lobbies, 1700 seats, a Barton theater organ, and an orchestra pit. Now, after ninety years of capital campaigns and restorations, the building has three auditoriums and is the center of the Michigan Theater Foundation, a world-class non-profit center for fine film and other cultural events. Its State Theatre, across the street, reopens this month after a well-earned renovation. Michigan Theater hosts the Ann Arbor Symphony Orchestra, Cinetopia International Film Festival (in partnership with the Detroit Institute of Arts), organ concerts, and other live-stage events. When days in the next few months get gray, slushy, and cold, the Michigan Theater is a wonderful refuge and it's equally delightful the rest of the year.
"I've seen this movie before" is a phrase in vogue for recurrent phenomena and so it seems with the autumn ritual of residency applications. Fourth-year medical students travel around the country as "sub-interns" to audition at training programs in hopes of securing 5 to 6-year residency slots. Yet, every annual cycle presents a unique array of new faces, talents, experiences, and energies of candidates visiting our Ann Arbor program. This recruiting season has been particularly good, marked by nearly 70 astonishing medical students who interviewed for four residency positions to start here on July 1, 2018, as the class of 2023.
Just as we rank the students, they rank us among the other programs they like and a computer makes the binding national match. Most applicants we see will become successful urologists and most programs they rank will train them excellently, evidence that our medical schools and professional organizations have created high standards, with narrow Gaussian distributions of quality. This is to say, the very best programs and candidates falling on the right side of the curve are not grossly dissimilar by most measures from the programs and candidates on the other side. A theoretical program variability curve (blue) and wider student applicant curve (red) illustrate my belief that some applicants are potentially "better" than any of our programs. That should be no great surprise, as it indicates Darwinian principles at work: some of our successors should, by all rights and intents, surpass those of us who teach them.
What does it take to go from applicant to successful resident? Most people we interview will become excellent residents and urologists who will impact their communities and practices significantly, and some will advance the field of urology in major ways. Before students create their preference lists, they need to get in the door for rotations and interviews. This requires good Step One board scores and excellent medical school performance data. Since most schools are "pass-fail," applicants must demonstrate noteworthy performance in their clinical clerkships, such as "honors" in their deans' summaries and strong letters of endorsement. When recommendations come from colleagues we know, with good track records of producing students who become excellent residents, we pay attention. Honorary society membership, selection to AOA for academic work or the Gold Humanitarianism Society, helps demarcate successful applicants. Exemplary social behavior is an important feature and successful performance on teams, such as college sports and humanitarian efforts, is also typical of our applicants.
Test metrics, honors, and accolades are surrogates for the attributes we seek in our residents and future colleagues. We want individuals with intellect, empathy, ingenuity, resilience, and good humor. Good residents and good colleagues tolerate personal inconvenience to help their patients and teams. Particular metaphors illustrate our affinities. The people we seek have the "fire in the belly" to do the daily work and to solve meaningful problems. They "go the extra mile," or add-on the "extra case" at the end of the day when the going gets tough. We need people who work well in teams, yet are effective leaders when the opportunity or need arises. Candidates similarly seek attributes of training programs. Surveys and "field notes" over the years identify important factors in play for applicant preferences such as program depth, established mentorships, institutional culture, geography, global opportunities, and climate.
Two new features of our program will come on line. Steve and Faith Brown of California created a scholarship for a medical student, preferably from UM, entering our urology residency each year. The Brown scholarship will help residents with research projects or unique educational experiences. An intermittent 5th residency/research position, intended for a physician-scientist and established with the NIH and AUA, will start in 2019 and last seven years.
The Gaussian distribution of residency programs, narrow and steep, reflects the fact that nearly all are fully capable of preparing trainees for excellent urologic careers. The wider applicant curve reflects my belief that many of our trainees have the capacity to be better than we (the faculty) are now. In fact, this is our goal. We want to train residents who will leverage the best of what they learn and see from faculty today to improve urology practice and research throughout their ultimate careers. In their own time, today's residents and fellows will discover new knowledge, recognize new paradigms, invent better technologies, create novel operative solutions, and find ways to deliver health care more safely, efficiently, generously, equitably, and with greater kindness. If we do our work properly, our trainees will be more adaptable and creative in the environments of their tomorrows, than we could be if we cloned ourselves.
Johann Carl Friedrich Gauss (1777-1855), the only child of a poor family, was born and raised in the Duchy of Brunswick, now Lower Saxony, Germany. A child prodigy, he attracted the interest of the Duke of Brunswick who supported his education locally and at Göttingen University. Gauss's doctoral thesis in 1797 offered a proof of the fundamental theorem of algebra, that every polynomial equation with real or complex coefficients has as many solutions as the highest power of its variable. The duke's philanthropic investment paid off well, as Gauss became known as "the foremost of mathematicians" (Princeps mathematicorum) and the most influential mathematician in the past millennia, impacting numerous areas of mathematics and science in general. Many echoes from Gauss's brain reverberate today. In addition to Gaussian distribution we have the Gauss unit, Gauss law, Gauss formula, Gauss platform, Gauss elimination, Gauss-Bonnet theorem, and even the Gauss rifle. The web reveals an astonishing array of Gauss's quotes, revealing a humorous and humanitarian mind. (Below: Daguerreotype of Gauss on his deathbed. Wikipedia.)
Universities are civilization's best bet for its future, teaching tomorrow's citizens and builders, and expanding today's knowledge. Universities explore "the nature of things" and public universities play a particularly important role. A quote by David Damrosch stays with me:
"A report by the Carnegie Council in 1980 began by asking how many Western institutions have shown real staying power across time. Beginning with 1530, the date of the founding of the Lutheran Church, the authors asked how many institutions that existed then can still be found now. The authors identified sixty-six in all: the Catholic Church, the Lutheran Church, the parliaments of Iceland and of the Isle of Man – and sixty-two universities (Three Thousand Futures)." [Damrosch, D. We Scholars. Harvard University Press. 1995, p. 18.]
Purposeful building of successive generations cannot be left to chance or entirely entrusted to government, religious entities, or the private sector. Nor should this be entrusted to any single university system, whether state or private. A diversity of universities, public, private, and ecclesiastical (in collegial or sometimes sharp competition with each other) will be the best way to educate successive generations, innovate technologies, and create and test new ideas for tomorrow. Universities must accommodate the immediate milieu and stakeholders of today, while taking the long view for subsequent generations. Gauss's university is exemplary.
The University of Göttingen was founded by King George II of England in 1734 (as Elector of Hanover) and quickly became a center for the nationalistic reawakening of the German lyric and national poetry. Encyclopaedia Britannica credits the university with releasing Germany "from the confines of the rationalism of the Enlightenment and from social convention." Gauss studied at Göttingen from 1795 – 1798, but around its centennial in 1837 the university took a reputational hit when seven professors were fired for political unrest. Luster was restored before its bicentennial particularly at its Mathematical Institute, that Gauss had once led. Göttingen has produced 40 Nobel prize winners including Max Born, James Franck, Werner Heisenberg, and Max von Laue. The strong mix of humanities and science at the University of Göttingen is noteworthy evidence that these two facets of creativity are inseparable, divided only by parochial and unimaginative perspectives. A century younger than Göttingen, The University of Michigan is no less rich in humanities and science. All universities need to figure out better ways to merge those two fundamental sides of knowledge.
Galens 91st annual Tag Days began yesterday and will run through tomorrow. Medical students and faculty at the University of Michigan created Galens Medical Society in 1914 for student advocacy and as a social bridge between students and teachers. The name choice is both obvious and obscure. Galen was one of the early great names in medical practice and study, but it remains a mystery as to why that particular name was selected for this medical society. Galens Society at Michigan created an honor system, obtained secure student lockers (theft was a problem even in those halcyon days), and established a student lounge. In 1918 Galens members held the first Smoker, a series of skits performed by Galens men. Galens shifted its focus in 1927 to raise money for children with Tag Days, wherein students solicited faculty and community members, a tradition that continues the first weekend of December in the Medical Center and the streets of Ann Arbor. The Silver Shovel Award began in 1937 to honor faculty who have shown extraordinary commitment to teaching medical students.
At some point Galens opened its doors to women medical students, reinvigorating the organization. Galens initiated the Mott 8th floor project in 1964 to house its Workshop for Children that had been ongoing since 1928, but lacked a permanent site. A chapel and student lounge were also created in that space. Galens contributed funds for the Mott Pediatric ICU in 1968 and in the 1980s made a similar contribution to St. Joseph Mercy Hospital for its Pediatric ICU. In 2006 Galens came up with $200,000 for the Child and Family Life Playrooms in the new Mott Hospital. In addition to the Mott Child and Family Life Program, Galens has supported Ozone House, Foundations Preschool, Children's Literacy Network, The Corner Health Center, and Special Days Camp, among other worthy projects.
Galens today includes about 120 medical students and 13 honorary faculty members. During Tag Days students on street corners sell tags that raise nearly $100,000 for Mott efforts and other children's programs in Washtenaw County. In addition to The Smoker, Galens supports a Welcome BBQ, a tailgate, and a year-end banquet. A Galens Loan Fund helps medical students for their interviewing costs, that easily can cost students $5,000 – $10,000 as they travel around the country in their fourth-year interviewing for residency. Next year's Smoker, by the way, will be March 2 and 3 at Lydia Mendelssohn Theatre.
Michigan men.
Francis Collins returned to Ann Arbor last month for the M Cubed Symposium and gave an inspiring talk that he called "NIH: National Institutes of Hope." As a faculty member here in the Department of Human Genetics, his team figured out the genetic basis of cystic fibrosis. He went on to co-direct the human genome project and is currently NIH Director. Collins spoke about the considerable footprint of UM in medical research and our relatively large portion of the NIH budget.
Dr. Collins offered three reasons for splicing "hope" into the NIH acronym. First is the role of the NIH in uncovering life's foundations; second is the NIH intent to translate discovery into health; and third is the synergy in the socialization of science, that is the idea that collaborations are the best way for the scientific community to "move forward, together."
The NIH origin dates back to July 16, 1798 when Congress established the Marine Hospital Service "for the relief of sick and disabled Seamen," recognizing that their healthcare was a responsibility of the government. The Marine Hospital Service fell under the Treasury Department and a monthly tax of twenty cents was deducted from the pay of merchant seamen, making this America's first prepaid health care system. Less than a year later, legislation extended the benefits of the Marine Hospital Service to Navy and Marine Corps personnel. In 1875 a new law directed the President to appoint a Surgeon General of the Marine Hospital Service with advice and consent from Senate. Interstate quarantine authority was granted by Congress in 1890. The name of the service was changed in 1902 to the Public Health and Marine Hospital Service, eventually growing into the NIH, now intended to improve knowledge and extend services to improve health. The current budget exceeds $32 billion.
John Park was recognized as Clinician-of-the-Year at the Michigan Medicine Awards Dinner last month. A superb pediatric urologist, quintessential teacher and mentor, and leader as Surgeon-in-Chief at Mott, John is one of the most respected and beloved clinicians of Michigan Medicine. The yearly awards celebration was instituted by former dean Allen Lichter, continued by Jim Woolliscroft, and now is fine-tuned by Marschall Runge, Carol Bradford, Bishr Omary, and David Spahlinger. (Below: Park family)
When calendar years close out, pundits tally major events and accomplishments, as if to predict what future generations might mark as notable for that year. Some events and findings this year, unrecognized by most of us likely will rise to great significance in future times. At this moment, as of December first, some breakthroughs of the year are already acclaimed as important, although much can yet happen for good or for bad this last month of the year.
Science magazine traditionally announces its "breakthrough of the year" with 9 runners-up, as a result of a "people's choice" poll. Likely contenders for that list will be: observation of gravitational waves by three separate observatories, thereby supporting Einstein's general relativity theory; CRISPR gene-editing to correct the mutation causing hypertrophic cardiomyopathy in a viable human embryo (similar work was reported in China a few years ago); neutron star collision (kilonova) witnessed at LIGO; and human-pig hybrid creation at Salk.
Editors and writers of Science magazine in 2016 picked the detection of gravitational waves as the breakthrough of the year announced in the December 2016 issue [Adrian Cho. The cosmos aquiver. Science. 354:1516, 2016]. Alternatively, another poll (of readers) listed the gravitational wave by the LIGO interferometer as number two, preferring as number one the breakthrough in tissue culture techniques that allow human embryos to be sustained ex vivo for nearly 2 weeks. The "people's choice" for number 3 was portable DNA sequencers, followed by an artificial intelligence milestone for number 4, and a finding on cell senescence and aging. My point is that human biology was central to 4 out of 5 of the 2016 breakthroughs and will likely be prominent in the 2017 choices.
December first, looking back, is noteworthy for historic airplane crashes. As the methodology of aviation checklists has been imported into medical practice, most visibly in the surgical arena, it is useful to cross-examine failures and successes in both fields. Two aviation disasters occurred on this particular day in 1974. TWA 514 crashed northwest of Dulles Airport killing all 92 on board. En route from Columbus to Washington National Airport (now Reagan) the plane was diverted to Dulles due to high crosswinds and slammed into the west slope of Mount Weather. Terminology discrepancy between flight crew and controllers, heavy down drafts, and reduced visibility from snow were blamed. U.S. Congressman Andy Jacobs, scheduled on that flight, had refused to pay a $20 seat upgrade and luckily took another plane. The same day, Northwest 6231 crashed near Stony Point, NY, killing only the three crew members flying the plane from JFK airport to Buffalo as a charter to pick up the Baltimore Colts, whose planned aircraft was grounded in Detroit by a snow storm. Failure to activate the pitot tube heater, presumably a checklist item, was the root cause, resulting erroneous airspeed readings, icing, and a stall. Both planes were Boeing 727s.
On this day in 1981 Inex-Adria Aviopromet Flight 1308, a Yugoslavian charter McDonnell Douglas MD-81 from Brnik Airport in Slovenia, crashed on approach to Ajaccio on Corsica. Air traffic control believed the plane was in a holding pattern over the sea and requested it to descend, although it was actually 9 miles inland. The crew knew the plane was over the island and was surprised at the instruction to descend from their holding pattern, repeating their uncertainty to ground control. Ajaccio Airport had no radar and flight controllers insisted on descent which took the plane right into Mont San-Pietro killing all 180 people on board. On investigation, communication confusion was named as main factor.
Coincidentally a few years later, on this particular date in 1984, NASA conducted the Controlled Impact Demonstration at Edwards Air Force Base, deliberately crashing a Boeing 720 flown remotely so as to study occupant crash survivability. (Picture below, Wikipedia.) Planes seem to be made more safely, but the human factors of miscommunication and deviation from routine procedure remain our Achilles heel.
As the urology chair search process unfolds many people will be engaged in trying to figure out the best fit for our department. Academic medicine seems to have convoluted the process of leadership succession, but it need not be difficult. A reasonable chair candidate should be someone who can take a team from good to great. A good candidate has a track record of excellence and national respect in his or her field, particularly in the essential deliverable of the department. Chairs who have failed nationally never passed these two bars.
The key requirement of a chair is to deliver the main functionalities of the department and enhance its essential deliverable. For us, that key deliverable is state-of-the-art clinical care in all domains of urology and with accessibility for anyone in Michigan or beyond who seeks our services. The essential deliverable is the milieu for our foundational responsibility of educating the next generation of urologists and urology health care workers trained in urology. The essential deliverable is also the stimulus and laboratory for our mission of discovery and research. A chair must retain and recruit excellent faculty and staff to build stability and depth of the department's critical units, while helping its people develop their careers and fulfill their aspirations.
Personal traits of kindness, moral center, integrity, trustworthiness, flexibility, high emotional quotient, and humor are important. These are difficult to ascertain in external applicants, while a few minor deviations noted over decades of interactions "in the trenches" can derail internal candidates. Intellectual ability to deal with stress, complexity, and ambiguity is necessary. A successful chair needs curiosity to keep up with urology, medicine in general, and the changing world as he or she guides a department. A personal sense of cosmopolitanism builds the diversity, equity, and inclusion necessary for a great team.
A number of organizational talents are critical. The chair must understand and articulate the mission of the organization, sharing its beliefs and values. The chair must listen well and understand the department's stakeholders. The chair must build teams, develop consensus, elicit a vision, and craft strategies with stakeholders. The chair should be a proven hands-on problem solver when necessary, yet be an excellent delegator. The chair must understand the social responsibility of the organization relative to its partners, community, region, nation, and world-at-large. A chair must steward and grow the departmental resources. I came to learn these attributes from leaders of my various career stations and particularly from dean Allen Lichter and coach David Bachrach.
What lies ahead. It may seem doubtful that many people will be talking about "the halcyon days of 2017" next year or beyond, yet who knows what lies ahead to reframe our perspective? Historians viewing certain domains such as Astros baseball, might indeed think 2017 was a golden, happy, and joyful time. Turbulence in the health care markets, the uncertainties of regulations such as MACRA, changing demographics, expanding comorbidities, domestic violence, and environmental deterioration may combine to make 2017 look better from the rear-view mirror than it seems now from our perspective in December of this year.
Secular stagnation, an idea proposed by American economist Alvin Hansen in 1938, suggested that economic progress after the Great Depression was restrained as investment opportunities were held back "by closing of the frontier and collapse of immigration" [Economist Aug 16, 2014]. The idea could be expanded to the thought that any great shock to the world-at-large is followed by a period of latency. One can only guess how historians someday will define the era in which we are presently immersed. Stagnation of human progress is evident in many parts of the world, encompassing diplomacy, human rights, food security, personal safety, health care, environmental quality, as well as economic growth. If one views the world through a dystopia lens, then tomorrow's metaphorical glass is half empty and this year may be viewed as relatively halcyon. With a more optimistic lens, if human progress ultimately wins the day, as history indicates, the year 2017 may not appear particularly halcyon.
This year ahead will be busy for the Department of Urology at the University of Michigan. A search committee for new chair begins with strong representation from our department. John Wei, Kate Kraft, and Scott Tomlins know our department well, and the other members of the committee are terrific choices as well. Our departmental retreat, April 14, will be a good time to take stock of the process. A special meeting on bladder cancer, the Teeter Symposium, is planned for May 4. Bob Teeter, a friend of our department, lost his life to bladder cancer a decade ago and since then knowledge of the biology of this disease had advanced greatly, as have surgical and medical treatments. The symposium will be an opportunity to see how far we have come and develop some paths for the future. We look forward to the Nesbit Reception at the AUA in San Francisco, Sunday, May 20. During the Ann Arbor Art Fairs, we will host the 12th Chang Lecture on Art and Medicine on July 19 and the next day will feature Hadley Wood of the Cleveland Clinic as the Duckett Lecturer and Rosalia Misseri of Riley Children's Hospital in Indianapolis as the Lapides Lecturer. Our Health Services Research Symposium will be September 13 and 14. The Nesbit Alumni Society meeting September 20-22 will feature our own alumnus Toby Chai, now professor of urology at Yale. The Montie Uro-oncology Lecture is planned for some time next autumn. In 2019 we begin centennial celebrations to transition into the second century of urology at the University of Michigan.
[Neighborhood leaves, in transition, 2017]
Posted in Academic medical center, Autumn, Darwin, December, Graduate medical education, Health care, History, Medical humanities, Nesbit Alumni Society, University of Michigan Health System
November matters
DAB What's New Nov 3, 2017
The matula, an historic symbol of the medical arts and title of this electronic periodical, was the transparent beaker used to examine urine in the pre-scientific days of health care, as people sought explanations for and expectations from their illnesses. Fear and uncertainty exacerbate human illnesses and our earliest prehistoric ancestors found comfort from their fellows in clans and caves to care for and sometimes heal them. The matula is a useful metaphor for the acts of looking, listening, and examining evidence to discover what really matters in clinical situations.
In ancient days what really mattered to people with illness or injury were the issues of treatment and prognosis: what can be done to help, what comes next, will I live, or will I die? The specific matter of diagnosis was most likely subsumed by the idea of what caused the problem. Gods, fates, cosmic forces, evil-doers, bad luck, or obvious injury were likely culprits before germ theory, organ-based dysfunctions, or other explanations based on a verifiable conceptual basis of health and illness. A sense of prognosis, however, was of practical value.
Uroscopists inspected urine for color, consistency, clarity, sediments, smell, and sometimes taste of urine, to find clues for treatment and prognosis. This was not illogical. Pink urine from infection or trauma might be followed by recovery. Gross blood and particulate sediments would suggest recurrent bladder stones. Scanty concentrated urine from dehydration might signal severe gastroenteritis and a grim prognosis. Uroscopy grew into a complex pseudoscience with fanciful claims of prognostic significance based on intricate characteristics of urine samples. Newer tools, such as the stethoscope and microscope superseded matulas and the future will bring better tools.
Thoughts about the future occasionally slide into dystopian visions and invite the question: what really matters to each of us? Putting aside occupational questions of healthcare professionals (making a diagnosis, ascertaining a treatment), political ideology (conservative or liberal, R or D, libertarian or socialist), or pragmatic issues (where do I live, what car do I drive, what's for lunch?), we each have our own beliefs, although ultimately most people share similar fundamental desires for safety, comfort, and peace of mind. Family and friends matter.
We cherish personal liberty, physically and intellectually. Beauty, curiosity, and clarity matter. Social matters are important to most people; kindness, truth, integrity, respect, belonging, and sustainability are essential in a civilized world. The last item may seem a bit out of place, but as we sustain health, welfare, independence, and safety, for ourselves, our families, our communities, and our descendants, by simple logic we need to sustain our environment.
With Michigan's gorgeous autumn colors fading in the rear-view mirror, November's matula brings Thanksgiving into sight and notably the iconic holiday images of Norman Rockwell. His Four Freedoms paintings, based on Franklin Roosevelt's State of the Union Address in 1941, illustrated the freedoms that FDR thought mattered greatly: freedom of speech, freedom of worship, freedom from want, and freedom from fear. These freedoms extended the sense of the liberty entrenched in the second paragraph of the Declaration of Independence.
"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the Pursuit of Happiness, – that to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, …"
Roosevelt's four freedoms are more specific than the liberty mentioned in The Declaration at the dawn of the Revolutionary War, although political liberty was not far from Roosevelt's mind when he gave the speech 11 months before the U.S. entry into World War II. The speech also slyly broke with America's non-interventionism, by advocating support for our allies already in armed conflict. The words of Roosevelt and paintings of Rockwell mattered greatly to Americans in the 1940's and they seem to matter now in this new century. Rockwell's Four Freedoms paintings appeared in the Saturday Evening Post in 1943 and were used in war bond posters and postage stamps.
Rockwell also painted enduring images of healthcare professionals, some modelled on his neighbor Dr. Donald E. Campbell. After this topic was discussed in previous pages of WN/MT (March 4 & May 6, 2016) the doctor's great granddaughter, Moira Dwyer, kindly sent us information and photographs that the family kept. Dr. Campbell, born in 1906, graduated in 1939 from Middlesex Medical School and practiced in Stockbridge, Massachusetts providing nearly the full spectrum of medical care to his community. He retired at 83 and died in 2001 at 95. Like the English physician, John Sassall, detailed in John Berger's book, A Fortunate Man, Campbell was an indelible part of his community, providing far more than clinical services for patients by going beyond the specificity of medical conditions of his patients to understand their co-morbidities, inner needs, and social constraints. [Matula Thoughts Oct, Nov, Dec. 2016 & Feb. 2017]
As a footnote to Dr. Campbell, Middlesex College of Medicine and Surgery was founded in 1914 in East Cambridge, Massachusetts and was affiliated with a hospital of the same name. The campus moved to Waltham in 1928 and by 1937, it also included schools of liberal arts, pharmacy, podiatry, and veterinary medicine in addition to its school of medicine. Accreditation by the AMA became problematic, ostensibly due to issues of funding, faculty, and facilities although many claimed the merit-based admission policy and unusually diverse student body of Middlesex grated on the far more homogeneous American medical establishment at mid-20th century. Medical schools then maintained ethnic and religious admission quotas and Middlesex was an unabashed outlier with its diverse student body. In 1946, the Middlesex trustees transferred the charter and campus, with the hope that the medical and veterinary schools would be continued, to a foundation that created Brandeis University two years later. Middlesex Medical School did not survive the transition to the new university.
It is a profound community asset to have a Campbell or Sassall and it is impossible to fully measure their impact as a citizen, leader, mentor, and role model. These essential anchors of society bring not just their professional skills, but also their values, leadership, and expectation of fairness to a community. They look out for the common man and particularly for the most vulnerable members of the community. It is no coincidence that a universal ploy of anarchists, revolutionaries, and authoritarian pretenders as seen widely across the planet, is assassination of these "honest brokers." The moral example and leadership of doctors such as Campbell and Sassall is our ultimate expectation for the medical professionals we teach. These mentors and role models act as epigenetic factors for the larger "superorganism" of humanity. They are operational factors between human genetics and civilization.
Education and training of physicians changed since 1939 when Campbell graduated medical school. The 4-year curriculum deepened with the growing scientific basis of biology and disease while graduate medical education (GME) also expanded with enlarging technology and new specialties of health care. The period of residency practice and study is now the career-defining facet of a doctor's learning. Nearly 80 years since Dr. Campbell's graduation, medical students enter fields of GME in as many as 150 areas of focused medical practice with learning experiences that may exceed twice the years the trainees spent in medical school.
Healthcare education differs from that of lawyers, engineers, and most other career paths. Physicians, pharmacists, nurses, and dentists require an immediate educational context of patient-care. The University of Michigan recognized this fact in 1869 when it converted a faculty house into a hospital, thereby becoming the first university to own and operate a medical center. We recognized this anew when we began to create a wider health care network, in the past few years, capable of supporting our large educational mission, now educating 900 MDs and health care PhDs, 1100 residents and fellows in medicine, as well as dentists, nurses, and pharmacists. One could easily argue that universities should offer a wider coherent educational milieu. A grander educational vision to include all parts of the health care workforce (physician assistants, surgical scrub technicians, medical assistants, etc.) would have a great effect on state economy and on our workforce pipeline. It could be done with robust partnerships not only with the UM Flint and Dearborn campuses, but also with our adjacent and regional community colleges.
In its more rudimentary days, the UM academic health center was distinguished by its implementation of fulltime clinical faculty, terminology indicating that physicians who practiced or taught exclusively within a teaching hospital had a fulltime salary independent of their patient care revenue at that site. In the early days of UMMS this model attracted national luminaries such as Charles de Nancrede in 1889 and Hugh Cabot in 1920. de Nancrede was an attending surgeon and clinical lecturer at Jefferson Medical College, among other Philadelphia medical institutions, and was a major name in American surgery as a clinician, teacher, and pioneer in antiseptic and aseptic technique. At Michigan he presided over the construction of the new West Hospital in 1892, established a world-class surgery department where he practiced exclusively, and wrote an influential textbook of surgery. [World J. Surg. 22:1175, 1998.] Cabot was an even more stellar addition, coming from Boston as an internationally known urologist, where he had become disillusioned by the monetary nature of medical practice.
The world of healthcare practice, education, and investigation is different in the 21st century. The few academic medical centers that will survive well in the future will be those with the best and brightest geographic fulltime faculty, the majority of whom will be busy clinicians. Their milieu may well depend upon robust clinical productivity that brings the most challenging clinical problems to them and their facilities, but this will also require a very substantial volume of more routine clinical work as the context for education of all learner groups and clinical trials, in addition to inspiring basic science investigation. This clinical milieu will require a robust array of endowed professorships to give faculty a modest disconnect from clinical practice to allow teaching and academic work.
Fellow professionals. Modern specialty-based health care has shifted emphasis from individual all-knowing utility-player doctors like Campbell and Sassall to large teams that deliver their parts of today's healthcare. The knowledge base, growing list of specialties, and technology of medicine today is so great that the centrality of a single physician is a model that no longer works well for health care delivery. Furthermore, linguistic confusion arises as other terms are awkwardly deployed to indicate all healthcare providers (not just physicians) more inclusively. This matter became acute as we have been creating bylaws for our new University of Michigan Medical Group (UMMG). A good nomenclature solution arose from Gerald Hickson, a Vanderbilt pediatrician (above), speaking to the UMMG this summer about programs that build professionalism and create a culture of safety. His phrase, fellow professionals, nicely includes MDs, DOs, nurses, PAs, physical therapists, podiatrists, occupational therapists, optometrists, respiratory therapists, pharmacists, medical assistants, etc. [Hickson et al. A complementary approach. Acad. Med. 82:1040, 2007]
Medical professionals are under stress today from many sources, but the idea of a career in medicine still drives some of the best and brightest young people into our work, as judged by the medical school and urology residency applicants we see each year. I've just read applications, personal statements, and letters of recommendations from nearly 70 candidates for our 4 positions to start next July, and again I am blown away by the breadth and depth of these fourth-year medical students who will, all too soon, become our successors as urologists. They will have to resist the pressures to commoditize, corporatize, and industrialize their work as the 21st century rolls along. The electronic record is one of the pressures. A paper in Health Affairs last April surveyed primary care physicians and found they spent 3.17 hours on computers (desktop medicine) for every 3.08 hours spent with patients. [Tai-Seale et al. Electronic health record logs. Health Affairs. 36:655, 2017.]
It is impossible to predict the world that will envelop our successors. The conceptual basis they will learn and the skills they acquire are merely momentary assets. Ideas and techniques will change as long as human progress continues. The values, mores, social skills, curiosity, imagination, and ultimate kindness of our successors will be the principle assets to distinguish their careers, their effects on their communities, and their value to society in general. The influence of their ambient role models is as important as the book-learning and clinical skills imparted in graduate medical education. The epigenetic nature of values, mores, social skills, and role models show us, our colleagues, and our successors how and when to deploy the vast stores of information and skills we have accumulated. Just as importantly, some among them will be inspired to discover new knowledge and develop new skills.
With Thanksgiving coming up, I'm appreciative for precarious and relative world peace, food security, respite from climactic disasters, and the happy, healthy, lives we may have. [Above: Jennie Augusta Brownscombe, The First Thanksgiving at Plymouth, 1914, Pilgrim Hall Museum, Plymouth, Massachusetts.] The great minds who have made this world so interesting are another blessing, people who looked at the world with clarity to make observations or find patterns that escaped everyone else at their moments.
The name, Conrad H. Waddington, probably doesn't spring to mind, but is worth consideration. Born on a tea estate in Kerala, India, around this time of year in 1905 this British developmental biologist introduced the concept and word epigenetics. At age four he was sent off to England to live with family members while the parents remained at work in India for the next 23 years. In England, a local druggist and distant relation, Dr. Doeg, took the boy under his wing and inspired his interest in sciences. At Cambridge, "Wad" took a Natural Sciences Trips (a flexible curriculum across sciences) and earned a First in geology in 1926. With a scholarship he studied moral philosophy and metaphysics at university, assumed a lectureship in zoology, and became a Fellow of Christ's College until 1942. During WWII he was involved in operational research for the Royal Air Force, and in 1947 became Professor of Animal Genetics at the University of Edinburgh where he worked for the rest of his life except for one year at Wesleyan University in Connecticut. Waddington's landmark paper in 1942 begins with four lovely sentences.
"Of all the branches of biology it is genetics, the science of heredity, which has been most successful in finding a way of analyzing an animal into representative units so that its nature can be indicated by a formula, as we represent a chemical compound by its appropriate symbols. Genetics has been able to do this because it studies animals in their simplest form, namely as fertilized eggs, in which all the complexity of the fully developed animal is implicit but not yet present. But knowledge about the nature of the fertilized egg is not derived directly from an examination of eggs; it is deduced from a consideration of the numbers and kinds of adults into which they develop. Thus genetics has to observe the phenotypes, the adult characteristics of animals, in order to reach conclusions about the genotypes, the hereditary constitutions which are its basic subject-matter." [Waddington. Endeavor. 1: 18-21, 1942]
Later on the first page he suggests the term epigenetics to encompass the "whole process of developmental processes" that carries genotypes into phenotypes. The influence of Dr. Doeg, whom Waddington called Grandpa, was no doubt significant. The specifics of Dr. Doeg eluded me as I read about Waddington. Too bad, because it would have been illuminating to understand the nature of the fruitful mentorship that shaped Waddington's curiosity, lucidity, communicative skills, and sociability that left him a context to discover what he did.
Black Bart, legendary stagecoach robber, committed his last robbery on this date in 1883. He specialized in Wells Fargo robbery, and it's a bit ironic that the bank's more recent history indicates it has internalized that larcenous bent to its own customers. Black Bart was actually Charles Earl Boles, variously known as Charley Bolton, a gentleman bandit in Northern California and Oregon. Born in Norfolk, England, he and his brothers joined the California Gold Rush in 1849. The brothers died and by 1854 Charles was married and living in Decatur, Illinois with a wife and four children. After serving in the Civil War he returned to California and gold prospecting in 1867, leaving his family behind. In 1871 Bolton wrote his wife and described an unpleasant encounter of some sort with Wells Fargo & Company agents and vowed revenge. He fulfilled the vow, adopting the name Black Bart, and robbed at least 28 coaches in California and Oregon, although never fired a weapon or harmed anybody. The last known robbery was in Calaveras County, between Copperopolis and Milton, when he was wounded in the hand while escaping. Detectives found personal items at the scene and through laundry marks traced a handkerchief to a San Francisco laundry on Bush Street. They quickly located Boles, living in nearby boarding house, and convicted him of the November 3 robbery.
Black Bart served four years at San Quentin and after release he was constantly shadowed by Wells Fargo detectives. In a letter to his wife he said he was tired of the attention, and disappeared after being last seen near Visalia on February 28, 1888. A distinctive feature of Black Bart was that he was consistently a gentleman, always polite and never using profanity. It might be said that he was a rare and exemplary professional in his business, living according to his values. His sense of mission will never be exactly known to us today, but Black Bart was somehow compelled to right some perceived wrong and, like most of us, he needed an income so Wells Fargo was a fitting opportunity.
Even in his risky occupation Black Bart remained kind and harmless, other than theft from a corporate entity of questionable kindness itself, it turns out. If he could act kindly in spite of living on the edge as he did, health care professionals such as us might consider him as a role model, although somewhat of a peculiar one. Somewhere along the line he must have had the parenting, mentorship, or experience that built his character of kindness, larcenous though it might have been. [Above book cover. Black Bart: Boulevardier Bandit. George Hoeper. Word Dancer Press, 1995]
Jack Lapides. As we unearth stories of Michigan Urology, colorful anecdotes come to light and many involve Jack Lapides. The personal story of a patient who underwent a life-changing Lapides vesicostomy was told on these pages in July and that gentleman was ultimately laid to rest in a ceremony at Arlington in August. Another story from a former medical student was that of Jack teaching the students the art of cystoscopy when he would ask the students to peer over his shoulder and look through the scope to describe what they saw.
It is said that Lapides sometimes mischievously disconnected the light source cord as someone leaned in to look and occasionally an uncertain student provided a fanciful description of the dark or black field. This may have been one origin of his Black Jack moniker, although just as likely it might have been related to the fear he struck among rookies in his expectation for high standards and excellence. Dr. Lapides's conferences were legendary. He was exacting and tough, requiring that all presentations be stripped of jargon and abbreviations. The IVP, for example, was intravenous pyelogram. Conferences today are more causal. The tradition of teaching conferences persists, but on a larger canvas since Lapides's days with 4-5 faculty, our scale having increased by a factor of 10. Just below is Thursday morning Grand Rounds. Further below is the Friday AM Mott imaging conference that follows a formal review of operations scheduled the following week. In both instances we have outgrown our rooms.
Yet another Lapides anecdote turned up last week when I was at the American College of Surgeons (ACS) meeting and spent an evening with Lou and Ginger Argenta (below: with Tony Atala of Wake Forest, in San Diego October, 2017).
Lou had been our plastic surgery head in my early years at Michigan and innovated, with Michael Morykwas at Wake Forest, the Vacuum-Assisted Closure (VAC) device, a paradigm-changing system to manage burns and wounds. For this he won the Jacobson Innovation Award from the ACS in 2016. Lou recalled how Jack Lapides, in his retirement years, took up welding and small engine repair, learning and teaching them at Washtenaw Community College. Jack kindly performed a welding repair on the broken bicycle of young Joey Argenta, and the work held up for years of further bicycle abuse.
Lapides stories will undoubtedly continue to emerge. The man and his work had a long reach.
What really matters to us, to our patients, to our colleagues, to our community, and our 7 billion global brethren is a deep question usually lost in the daily hustle of life. Most people have roughly similar ideas about what matters, although each has a particular take on things. Donald Campbell, Charles de Nancrede, Charley Bolton, Jack Lapides, Dr. Doeg, CW Waddington, FDR, and Rockwell had their particular world views that shaped their legacies. All, no doubt, shared many of the things that mattered to them, although each likely ordered and interpreted those characteristics idiosyncratically, perhaps Black Bart most peculiarly.
It is no accident that the four essential freedoms that Roosevelt identified have a strong basis in health care. Freedom from want is most obviously tied into food security, but it could just as easily be interpreted as freedom from needs that rationally include shelter and health care. Freedom from fear was illustrated by Rockwell as a fear of illness, but safety and personal security could just as easily have been the visual that Rockwell used. Liberty in the political sense is not so far from liberty in its mobility sense. An authoritarian regime may enforce curfews or travel restrictions, just as health conditions restrict people from being out and about to participate fully in society. If governments are to promote life, liberty, and the pursuit of happiness, the four freedoms are essential.
Human values and role models are the factors that translate human beings into the superorganism of human civilization. Those factors can go the way of apoptosis or can epigenetically build a prosperous, just, beautiful, robust, and sustainable version of itself for the next generation.
[Autumn foliage, my neighborhood 2017]
Posted in Academia, Academic medical center, Graduate medical education, Health care, Medical education, Medical humanities, Nesbit Alumni Society, University of Michigan Health System, Winter
Matula Thoughts July 7, 2017
DAB What's New July 7, 2017
The Fourth, stories, & art
This commentary from the University of Michigan Department of Urology is sent out on the first Friday of each month in two versions, the email What's New publication and the web posting matulathoughts.org. Matula is an ancient term for diagnostic flasks once used to inspect urine.
July delivers a new cadre of interns/residents to hospitals around the country in the midst of divisive national controversy over healthcare. Momentary acronyms – ACA, MACRA, MIPS, AHCA, BCRA, etc. – rivet public attention, just as the next acronyms de jour will do a few years hence. Whatever paradigms and regulations spill out of Washington, the daily clinical work of healthcare, education of our next generation, and expansion of knowledge and technology will continue. New house officers leaping out of their starting gates this month may scarcely notice the regulatory nuances and social policy debates. I hardly noticed such matters at a similar time in my life in 1971, but today the impact of healthcare legislation and regulation seems increasingly important. These matters, furthermore, are deeply linked to the principles celebrated this past week, because foremost in America's ongoing republican experiment is belief in human rights and self-determination and these are inextricable from health.
July 4th represents a pause of personal freedom and relaxation for most Americans. In addition to the general right of freedom, personal freedom requires a shared sense of social justice built on laws specific to given nations, societies and localities, such as speed limits in school zones, zoning rules, or sales taxes, yet aligned with universal human rights. Not all local laws meet the bar of social justice, examples are voting restrictions, sedition or blasphemy laws, childhood marriage, and eugenic sterilization. A book on the document that made the Fourth of July possible, Our Declaration written in 2014 by Danielle Allen, dissected The Declaration of Independence word-by-word, examined the milieu in which it was constructed, and distilled the underlying principles in its second paragraph ("We hold these truths to be self-evident …") down to three "truths" after accounting for punctuation and syntax:
all people are equal in being endowed with the rights of life, liberty, and the pursuit of happiness, among others;
humans build governments to secure these rights and political legitimacy rests upon the consent of the governed;
when governments fail to protect these rights, people have a right to revolt. [Our Declaration. Liveright Publishing Corp. NY. 2014. 153.]
[Fireworks, Barton Hills 2017]
The Declaration, read from a strict originalist or textualist perspective, or even interpreted from a common-sense viewpoint, places healthcare soundly within all three of those "inalienable rights." Life speaks for itself, from birth through childhood and adulthood navigating the hazards of trauma, disease, and disability. Liberty is the matter of self-determination, a basic tenant of our nation and democracy. This is the freedom to make judgments, speak freely, pursue education, choose careers, or adopt life styles. Liberty requires personal independence and mobility, assets that logically depend upon health. The writers of The Declaration were specific in selecting pursuit of happiness as an inalienable right. The word, happiness, appears twice in the second paragraph of The Declaration. Happiness may have had a subtly different meaning 241 years ago, but it is likely that the Committee of Five charged by Congress to write The Declaration (Thomas Jefferson, John Adams, Ben Franklin, Roger Sherman, and Robert Livingston) did not intend a trivial or hedonistic sense. They recognized that people, individually and equally, shared the right to pursue happiness as they themselves determined that happiness and government was intended to be in service to its people: "…Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness."
The Lancet last month included a relevant statement from a World Health Organization Working Group, speaking for health and human rights of women, children, and adolescents, but applying equally to all human beings and expressing the principles of The Declaration. The particular vulnerability of women, children, and adolescents throughout most of the world is a tragic reality built on countless stories, known and unknown. The Working Group comment extends beyond its particular portfolio because all human beings are vulnerable to catastrophes of climate, geology, famine, war, oppression, violence, economics, and biology.
"The powerful interplay between health and the human rights of women, children, and adolescents forms the cornerstone of the global development agenda. When their right to health is upheld, their access to all other human rights is enhanced. The corollary holds true. When their right to health is denied, the impacts inhibit their exercise of other human rights, undermining their potential …" [Halonen T, Jilani H, Gilmore K, Bustreo F. The Lancet. 389:2087-2089, 2017]
House officers and fellows explain their attraction to medical careers, at least in part, by belief in social justice and the opportunity to help people. Medical school debt, duty hours, documentation-compliance, RVUs, and personal well-being dampen those original attractors. Acrimonious debates on healthcare legislation center around views of healthcare as a right as opposed to healthcare as a commodity and personal responsibility. The words right and responsibility require deeper consideration, for example in a recent radio interview Tom DeLay, former U.S. Representative from Texas (1979-1983, 1985-2006) and House Majority Leader (2003-2005) stated he doesn't believe that health is a right, but rather a responsibility. [Interview on NPR with Jeanine Herbst March 22, 2017.] His point that government has no "constitutional role in health insurance" is accurate from a textual Constitutional perspective, however to reduce the generality of healthcare to the particularity of health care insurance is neither logical nor helpful in the national debate. I use the DeLay quote only to introduce the consideration of healthcare as a right, not because of any claim to healthcare expertise or salutary wisdom regarding social justice he might offer.
[House officers Matt Lee & Ian McLaren choosing freedom over local rules.]
The truth in healthcare is close to home for most people. Health care involves each of us from antenatal days to final days of life. It is not productive to frame the national healthcare debate in the context of healthcare insurance, as insurance is only one method to fund a nation's healthcare needs. Viewing the enormous panorama of national healthcare from only the insurance perspective makes no more sense than expecting the motor vehicle insurance sector to cover all motor vehicle costs including purchase, gasoline, cleaning, maintenance, safety inspections, collision repair, and damage from acts of nature, as well as highway safety, research and development, petrochemical sourcing, and traffic control.
The insurance industry, arguably, began at Lloyds Coffee House in 1686 of London as a source of shipping news and later marine insurance to mitigate catastrophic risks of sea commerce (above c. 1800 unknown cartoonist. Wikipedia). Insurance did not cover all expenses of sea trade, it covered true catastrophe, not operating costs, torn sails, or men overboard. The origin and evolution of American health insurance and the co-mingling of it with employment status is a story with many twists and turns, and federal involvement added further complexity. The result is an intertwined morass of funding streams and regulations, kinda looking like the Lloyd's cartoon above. Rather than partisan ping pong, the solution to the national healthcare dilemma requires thoughtful bipartisan consideration of a framework to define rational public and private domains, responsibilities, and funding.
Debate, essential to democracy, requires free speech and an open society that embraces education and cosmopolitanism. Conversations that challenge opinions, introduce ideas, and work toward consensus are fundamental to civic life as well as just and constructive public policies. This is how democracy works best, whether on national stages or in local workplaces.
We bring debate to Michigan Urology with point-counterpoint sessions at Grand Rounds when two residents square off with contrasting points of view to sway the rest of us. Our discussions are more prosaic than debates of health care as a right or commodity, because we are focused on learning urology. For example, Parth Shah recently offered the opinion that radical cystectomy should be performed by traditional open technique while Zach Koloff argued for the robotic platform (pictured above). They reinforced their positions with historical perspective and current data, deploying classic elements of argument. The impeccable characters of Zach and Parth represented ethos, their data supported logos of their claims, and considerations of pain, costs, complications, learning curves, and fiduciary responsibility bore pathos in the traditional rhetoric triad. The hospital conference room, newly refinished, was pretty much at capacity with about 45 in attendance including the usual 4-6 lurking at the back of the room with coffee and opportunity for stealthy egress.
The recurring biologic experiment of civilization evolved occasionally from the social networks animals depend upon to maintain each generation. A few eusocial species, if I may flip back to the writings of E.O. Wilson, create societies that successfully and become durable "megaspecies" in and of themselves. Wasp, bees, and ants are most notable, using chemicals or motions for communication. Specific signals trigger unified mass social actions such as directional movement, panic, or war. Ants, for example, manage their colonies with pheromones.
[Above: marching fire ants, Stephen Ausmus http://www.ars.usda.gov/is/graphics/photos/dec04/k11622-1.htm]
The human advantage with civilizations is an ability to build and change them over centuries through communications transcending many generations and even millennia, allowing learning, creativity, and innovation. Individuals apply critical thinking, reexamine assumptions, experiment, analyze methodologically, and cooperate for durable change, passing information along to successive generations. Individuals naturally have individual points of view and debate allows cooperation and learning, leading to resolution, reconciliation, and centrism. A strong center is essential for robust civilization, but just as ants and bees, humans are subject to mass manipulation by signals that, usually for us are money, ideology, propaganda, quackery, or charisma.
Conspiracy theories attract and entertain. We are drawn to them, being hardwired to favor stories that fit our predispositions or play to our anxieties. Conspiracy ideas provide lazy mental short-circuits that displace critical thinking and rational re-examination of assumptions. Some conspiracies, of course, prove authentic, although my limited experience in the military and as an amateur student of history, is that major conspiracies are unlikely to remain long-concealed. Democracy is leaky due to First Amendment protections of free speech. Rare exceptions, such as campaigns that "loose lips sink ships" or the Manhattan Project, demonstrate that free society can maintain secrecy for critical intervals on rare occasions when the need is essential and widely understood. The rarity of these exceptions preserves their exceptionalism. When a regime tilts toward authoritarian rule and censorship becomes common, democracy slides away.
It is not wrong that news sources are polarized. The left side of the political spectrum reads left-sided sources while the right reads right-sided sources, and everyone blends opinions, facts, and stories to support their myths and to ascertain facts. The middle of the political spectrum is where democracy finds its balance, but sources of news and opinion that the center trusts are uncertain and conspiracy fears can spread like viruses.
On this day in 1947 Major Jesse Marcel, intelligence officer of the 509th Bomber Group at Roswell Army Air Field inspected a debris field where an incident was claimed to have happened. [Above: Roswell Daily Record, July 8, 1947] Stories still emanate from that incident, blending facts and myths with no commonly-held authoritative version, but only colorful conspiracy theories. Those of us who grew up with the original X-Files series (1993-2002), centered around Roswell-type mysteries, are familiar with the haunting tune and the invitation to further inquiry: "the truth is out there." The quest for truth is humanity's big challenge.
All living creatures discern information from ambient noise. We humans create stories out of information and from the stories invent myths, models, and theories to derive meaning and utility. Careful analysis, by verification or scientific testing, pulls truth from facts, myths, models, and theories, nonetheless, truth remains elusive. The intersection of news and entertainment risks confusion and credibility as when the radio broadcast War of the Worlds in 1938 by Orson Wells created a minor panic for listeners who tuned in after its introduction as a radio play and thought that Martians were actually invading Earth. When trusted news anchors portray their roles in TV and film fiction they diminish their credibility. Worse, deliberate fake news tilts political opinion and instigates conspiracy fears that cannibalize civilized society by devouring trust that is the currency of civilized people.
True facts. The story of Jack Lapides, former chief of urology here at Michigan, educator, and innovator (above) was briefly told in an obituary column his sister requested after he passed away. [New York Times. Nov 19, 1995] (The published version has a single typo, introduced by the newspaper that must have thought the reference to Charles Huggins was "Charles Higgins.") Jack's surgical accomplishments continue to show up in urology clinics around the world, illustrating the long reach of an innovative surgeon. Surgeons fix problems, and one of Jack's surgical innovations was the vesicostomy, a solution for bladder and sphincteric dysfunction by making an opening on the abdominal wall.
The concept and practice of urinary diversion preceded Lapides by many decades with the standard of care for neuropathic bladder in the mid-20th century consisting of suprapubic cystotomy, ureterosigmoidostomy, ureteroileostomy, cutaneous ureterostomy or nephrostomy. Lapides favored vesicostomy to eliminate urinary stasis, high pressures, and urethral incontinence, but standard ostomy devices were unreliable: "Initially, we employed the usual types of fecal colostomy devices for collecting the urine, but soon became disenchanted with the various appliances because of bulkiness, leaking of urine, skin reaction, malodor, and difficulty in changing the apparatus." [Lapides J, Boyd R, Fellman SL. A urinary ileostomy device. J Urol. 1958. 79:353-355.] Lapides created a device utilizing a rubber ring with changeable collecting condoms, being rapidly replaceable, streamlined and more acceptable to patients. As it gained popularity it came to be known as the Lapides urinary ileostomy. [Lapides J, Ajemian EP, Lichtwardt JR. Cutaneous vesicostomy. J.Urol. 1960. 84:609-14.]
Pediatric urologists utilize vesicostomy occasionally. Keith Schneider, pediatric surgeon in New York, and John Duckett, pediatric urologist in Philadelphia, subsequently described vesicostomy techniques of their own, but these were mostly replaced by Lapides's clean intermittent catheterization methods after 1971 and the reconstruction approaches of W. Hardy Hendren. We honor the Duckett and Lapides names with lectureships here in Ann Arbor in July, as the first academic events of the residency training season. I carry the Lapides name with my endowed professorship and Hardy (mentor to John Park) continues to be an inspiration and friend to many of us in Ann Arbor.
Intersecting story. Last year our departmental office got a call from Peggy Hawkins of Chevy Chase, Maryland, who identified herself as the sister of a former Lapides patient in need of help. Her brother, we can call Larry, was living in Florida and dependent on a vesicostomy Lapides created in June, 1968, but Larry was having trouble obtaining stomal supplies. Peggy, recalling the name Lapides, contacted our office for help. I called Larry and we got him in touch with our UM stomal experts who found some solutions.
Peggy called back recently to tell me that Larry recently passed away and filled me in on Larry's amazing story. She assures me that Larry would have been pleased to share the following details of his life, particularly the importance of his vesicostomy to him.
Born in 1943, Larry was the only son in a family with two sisters. Popular and athletic, he played football and ran track in high school. After graduation from college with a major in political science he joined the United States Army as a Second Lieutenant and married his girl-friend. Larry was sent to Vietnam with the 173rd Airborne Brigade in 1967. The Tét Offensive changed his life. Launched on January 30, 1968 by 80,000 North Vietnamese and Viet Cong forces during the Tét lunar new year holiday, the offensive was a coordinated series of attacks on over 100 cities and towns in South Vietnam. A mortar round that first day exploded just behind Larry causing tremendous concussive injury to his back and spinal cord with extensive shrapnel injuries, particularly to lung, liver, and upper extremities. The triage officer didn't expect him to live, but Larry defied expectations and survived first to the field hospital, then to a general hospital in Japan, and next to Valley Forge Army Hospital in Pennsylvania, but with paraplegia and consequent lower urinary tract dysfunction that translated to sepsis and upper tract deterioration.
His medical condition continued to decline at Valley Forge and around this time a son was born. Larry separated from the Army in June, 1968 and was sent to the Ann Arbor VA that month where he came under the care of Jack Lapides who understood the deleterious nature of high pressures in the neurogenic bladder who explained that vesicostomy might extend Larry's life another ten years, Peggy recalled. The procedure that June turned around Larry's deteriorating clinical course and provided him another 48 years of independent life without urinary tract problems as long as he had access to stomal supplies.
After recovering from the operation and stabilization of his health Larry enrolled in law school in the fall of 1969, living in a nearby apartment with reasonable wheelchair access. With his Juris Doctorate he moved to Florida in 1972 mainly because of the flat terrain and more favorable climate, finding work in politics early on as an advocate for Veterans in Tallahassee. Larry received a Purple Heart and Bronze Star (above) with a "V" Device (for valor) in 1974. In 1978 he ran for public office and served 4 terms (1978-1986) in the Florida House of Representatives where he chaired the Veterans Affairs Committee and impacted a groundbreaking generic drug law. He was elected Dade County Commissioner 1988-1994 and sponsored nation's first family leave ordinance (Miami-Dade employees 1992), helped the Miami community recover after Hurricane Andrew and found creative solutions to the influx of Haitian immigrants in Jackson Memorial Hospital and Dade County Public Schools. Larry served on the Board of Vietnam Veterans of America. His network of political friends included Bill Clinton and Senator Tom Harkin, who introduced the Americans with Disabilities Act in the Senate. Larry's son died at age 34 in 2002, leaving Larry 2 grandchildren – a granddaughter who teaches kindergarten and a grandson currently serving in the Army. His step-son works for the U.S. Secret Service.
During his 48 years with a stoma Larry was able to engage socially and professionally. Never in those 48 years did he have a UTI, upper tract problems, or stomal problems, although access to stomal appliances, necessary for daily peace of mind, became increasingly difficult as the market for them disappeared. Larry died recently from multisystem problems, but without urinary tract issues. He will be buried at Arlington National Cemetery.
The Tét Offensive of 1968 continued through February. Although a military defeat for the North it intensified the American public opposition to the war and created a crisis in the Johnson administration. The "credibility gap" that had become apparent in 1967 widened in 1968, the year US casualties peaked with 16,592 soldiers killed. In February that year the US Selective service called for a draft of 48,000 men and on February 28 Secretary of Defense Robert McNamara stepped down from office. McNamara had been a long-time college friend of my UCLA urology professor Willard Goodwin and coincidentally lived in Ann Arbor for a short period as president of Ford Motor Company. As early as mid-1966 McNamara, as defense secretary believed that "there was no reasonable way to bring the war to an end soon" and that we should quickly find a political solution with North Vietnam and the Viet Cong. These were marginal opinions in the Johnson administration. [McNamara. In Retrospect. 1995. P 262] Many conspiracy theories abounded about the Vietnam War and some still resonate, but McNamara's book lays out the story clearly, explaining the mistakes of management, failures of duty, and sins of pride led to escalation of conflict and flew out of control. The Fog of War. Lessons from the Life of Robert S. McNamara, a film by Errol Morris and a book by James Blight and Janet Lang, explains the cautionary tale.
Chang Lecture. Medicine without art is a commodity. Not to disparage commodities, we expect them to be dependable, available, and standard in quality. With health care however we prize human values of excellence, kindness, discernment, attention, discovery, innovation, and even virtuosity. For all of us as patients and families, our healthcare needs and expectations go beyond mere provision of commodities. Many services in medicine can be managed as commodities: blood pressure screenings, flu shots, blood draws, and dental hygiene are typical examples, although even these can be done artfully or not. The routine blood pressure check requires thoughtful matching of cuff to body size and a few minutes of relaxation that puts the recipient at ease. Any human performance can be given with care, enthusiasm, and art – or not.
My aunt Evelyn Brodzinski, an artist, once said "Art is anything that is choice" after I asked her "What is art?" I quote her definition often. Art consists of the choices we make in the performances we give, whether delivery of a job, doodling on paper, whistling a tune, writing an essay, taking a picture, drawing a blood sample, or doing a surgical procedure. Any vocation can and should be performed artfully. Universities have a duty to propel this aspiration in all their fields of study, and the artful provision of healthcare should be at the top of any list of fields. The study of art is the study of choices in the world.
[Above: Lawrence exhibit Gibbs Museum, Charleston, SC]
We began the Chang Lecture on Art and Medicine in recognition of this obligation of our university. Such a lecture could just as easily come out of any of the 30 departments in our Medical School. It could also have come from Michigan's Department of Art History or School of Social Work. We brought it forward from the Department of Urology inspired by the linkage of art and medicine in the family of Dr. Cheng-Yang Chang, a urologist who trained and practiced at the University of Michigan, as well as founded a medical school in Taiwan and later practiced in Flint. His father, Ku-Nien Chang was a famous painter in China and Dr. Chang's oldest son is a urologist in Albany NY, trained here in Ann Arbor under Ed McGuire. Dr. Chang's youngest son is a financial analyst in Chicago and one of UM's best alumni supporters. This year Dr. David Watts, a prominent gastroenterologist in San Francisco and nationally-known humanist, will give the Chang Lecture July 20, 5 PM, Ford Auditorium.
[Life and the pursuit of happiness on Liberty. Art Fair. 2016]
Thanks for reading What's New and Matula Thoughts.
Posted in Academic medical center, Ann Arbor summer, Health care, Maize and Blue, Medical education, Medical humanities, Nesbit Alumni Society, University of Michigan, University of Michigan Health System
Matula Thoughts May 5, 2017
DAB What's New May 5, 2017
Ideas, evidence, & anniversaries
Ideas and evidence, that is information indicating whether ideas or propositions are true, have been assembling at increasing rates over the past dozen millennia of human progress and Michelangelo's Hand of God, Creation of Adam illustrates this concept beautifully, with the sagittal brain embodying mankind's divine creative spark (Sistine Chapel fresco. c. 1511). [See Meshberger in JAMA. 264;1837, 1990] The University of Michigan has been a significant player for the past 2 centuries of that narrative. The university launched its bicentennial celebration last month, the Medical School had its 150th anniversary (sesquicentennial) 17 years ago, and in a few years the Urology Department will have its own centennial. These are not just self-congratulatory moments, but worthy celebrations given the impact of each of these three entities.
Long preceding our particular institution, universities began in medieval Europe as ecclesiastical places of learning, teaching, and study. Mostly shedding their sectarian roots over ensuing centuries universities became, in turn, technical schools, research centers, professional schools, and now giant enterprises of academia that also aggregate sophisticated athletic teams, musical societies, technology transfer businesses, and health systems. Most fundamentally, universities teach the next generation of society and address the world's problems, generating new ideas and finding evidence to arbitrate which facts are true facts (in the terminology, once again, of Don Coffey). Universities are humanity's best bet as honest brokers for tomorrow to teach our successors, build better societies, and pursue truth.
The University of Michigan, Medical School, and Urology Department have much to celebrate. The university originated as a small school in Detroit in 1817, the Medical School began in 1850 in an Ann Arbor classroom for 92 students, and Michigan Urology claims the 1920 arrival of Hugh Cabot (below) for its birth. Cabots were big figures in American medicine. Older cousin Arthur Tracey Cabot was one of America's first genitourinary specialists, a founding member of the American Association of Genitourinary Surgeons, and Hugh's brother Richard was a celebrated Boston internist. Hugh Cabot's life was deeply impacted by military service in France during WWI. Returning to Boston in 1917 and unfulfilled in his private practice Cabot jumped at the chance to come to Michigan as fulltime surgery chair. He quickly became dean and in 1926 opened a modern hospital (1000 beds) with a multispecialty academic medical practice that defined 20th century medicine. Cabot's first 2 urology trainees were Charles Huggins and Reed Nesbit. One would win a Nobel Prize and the other would shape the future of clinical and academic urology, in addition to succeeding Cabot as the urologist of record in Ann Arbor. [McDougal, Spence, Bloom, Uznis. Hugh Cabot. Urology. 50:648, 1997.]
Humans are natural historians and find it pleasing, useful, or sobering to rewind the past with anniversaries, centennials, or other markers that inform, inspire, or caution. For example, on today's date in 1864 the Battle of the Wilderness began, a time when our Medical School was fairly new. The Civil War was much on the minds of Michigan medical students then, who would go off to fight for the north or south after graduation. Wilderness was the first battle of Lt. General Ulysses S. Grant's 1864 Virginia Overland Campaign and, although tactically inconclusive with heavy losses on both sides, it thrust Grant into a national spotlight carrying him eventually into the White House.
The disabilities and deaths of the Civil War affected most people and families in the United States. Wars, with countless traumatic crises for soldiers and civilians, perversely stimulate improvements in healthcare. Infection and antisepsis were not understood in 1864 and even minor wounds from musket balls or the more accurate Minié ball, prominent in the Crimean War and American Civil War, became lethal long after the instant of injury because of subsequent sepsis. [Above: Battle of the Wilderness; near Todd's Tavern, Orange County, Virginia, May 6, 1864. Imagined scene in the Civil War Print Series by Louis Kurz and Alexander Allison c. 1887.] Fifty years later antiseptic technique was commonplace and the surgical repertoire has expanded greatly when the U.S entered WWI, ridiculously claimed as "the war to end all war." That horrendous conflict, however, not only gets repeated, but is ever more horrendous as technology expands weaponry. The experiences of medical personnel like Cabot in WWI translated into new knowledge, skills, specialties, and systems that refined health care in the world that followed, until the next wars.
Michigan's Medical School had been open for 11 years when the Civil War began and the 2 years of lectures needed to produce an MD hadn't changed much. Dogma filled the curriculum with little evidence for medical practice beyond personal experiences. The educational process was two-dimensional, consisting of faculty vs. students in classrooms. The lectures included concepts as ancient as Hippocratic and Galenic theories of little use in the real world. Medical students had only simplistic understanding of trauma based on gross anatomy and lacking any sense of physiology, infectious disease, or cellular response to injury. Trauma care was mainly a matter of bandaging and crude orthopedic management. Anesthesia was rudimentary and surgical options beyond amputation were few. Most of what was taught in medical school as facts of the time would vanish under the scrutiny of science and emerging medical disciplines enlarged the curriculum in length and content. A UM hospital in 1869 (initially a dormitory for patients undergoing surgery in the medical school – shown below) opened a third dimension of inpatient clinical experience at bedsides as medical subspecialties began to form. Laboratory instruction, in emerging biosciences, provided a fourth dimension of medical education as a verifiable conceptual basis of health care was assembling.
Successive hospital iterations offered increasingly complex clinical experiences for medical students as well as patients and by the time of the 1910 Flexner report didactic classroom and laboratory experiences were equivalent to patient care experiences in the Medical School curriculum time and budget. An outpatient building in 1953 added a fifth dimension of ambulatory care that, in its own turn over the next 50 years, would exceed the scale of inpatient experience as medical specialties required more outpatient learning than bedside education. To maintain a clinical and scientific footprint for 700 medical students, 200 Ph.D. candidates, and 1100 residents and fellows, it became evident that a new dimension of statewide clinical opportunities and affiliations would be necessary. This has been happening over the past 15 years with Livonia, East Ann Arbor, Brighton, Northville, a growing number of professional service agreements, and regional affiliations such as MidMichigan and MetroHealth that create opportunities for "population health management", for the University of Michigan Health System (now Michigan Medicine) representing a sixth dimension of health care education. In many respects, this new paradigm is as big a leap into the future as that first university hospital was in 1869.
Just as during the Civil War, WW1, WW2, Korea, or Vietnam (on the minds of my school cohort), national and international conflicts will affect today's medical students who are in jeopardy, after graduation, of being thrust into action using their newfound knowledge and skills in dire circumstances of armed conflict.
Part – whole dilemma. One difficulty in healthcare today is the matter of deploying specialties for the care of patients, while keeping the whole of the patient in perspective. The specialties formed as 20th century ideas and evidence enriched the practice of medicine and the curriculum of medical schools. New areas of focused practice led to a new layer of education for medical students after graduation, known as residency training. Parallel and complementary subspecialties and epistemologies similarly formed in the sister healthcare sciences, such as nursing, pharmacy, sociology, psychology public health, and engineering here at Michigan and around the world. In 1933 the American Board of Medical Specialties (ABMS) began to consolidate emerging medical specialties to assure the public of the training, qualifications, and professionalism of medical specialists. By 1984 Human Genetics was added to the specialty roster and 24 medical specialties were in play, as medical practice was becoming increasingly complex and fragmented. The ABMS then stopped adding new boards and chose to manage new areas of practice through subspecialty certification or joint certification of emerging areas of practice among specific boards. This seems to have worked out well so far with 150 areas of specialties and subspecialties now in practice. [Above: residents James Tracey, Parth Shah, and Rita Jen sorting out the work for the day after morning conference.]
No single person can successfully manage this proliferation of knowledge, skills, and technology on behalf of patients, so all parts of a given health care team must work together. The idea of a primary care gate-keeper is not working well as a coordinator of care or as a focal point to ration care. This is the "part-whole" dilemma; that is, how to reconcile the parts with the whole. We also see this socially and politically in managing a multicultural society. The same issue plays out in universities among competing and collaborating disciplines. Sociobiologist E.O. Wilson makes the case that interdisciplinarity is how the most important work for the human future is likely to take place. [EO Wilson. Consilience.] Interdisciplinarity in the Twentieth Century, the subtitle of a book by Harvey Graff, examines the part-whole relationship in universities, reviewed by Peled from McGill who concluded:
"Graff emphasizes the dynamic interdependence between knowledge, scientific epistemologies, and (inter) disciplinarity, while remaining wary of proposing any simple definitions. Instead, he stresses the importance of egalitarian exchanges and the role of history and the humanities in the study of interdisciplinarity. Although Undisciplining Knowledge provides insightful answers to largely unexplored questions, its main contribution lies in refining and reframing these questions for the benefit of historians of science and interdisciplinary researchers." [Undisciplining Knowledge. Interdisciplinarity in the Twentieth Century. HJ Graff. Johns Hopkins University Press. 2015. Yael Peled. The domain of the disciples. Science. 350:168, 2015.]
Note the phrases "egalitarian exchanges" and "the role of history and the humanities." Interdisciplinarity today may seem novel and groundbreaking, but it will likely transform into new fields of work and knowledge in the near future just as history shows in Michigan's Medical School curriculum.
Evidence. The Stratton Brothers Trial began on this day in May, 1905, the first occasion for fingerprint evidence to obtain conviction in a murder trial. Alfred Stratton (born 1882) and his brother Albert (born 1884) were the first people convicted in for murder based on fingerprint evidence. The case, otherwise known as the Mask Murders (stocking-top masks left at the crime scene – below), the Deptford Murders (the location), or the Farrow Murders (the last name of the victims) initiated the interdisciplinarity of law and science (now, forensic science). A smudge on the empty cashbox looked suspicious to Detective Inspector Charles Collins, who wrapped up the box and took it to the newly established Fingerprinting Bureau at Scotland Yard. Alfred's right thumb was a perfect match. The conviction ended up in execution of the brothers on May 23 at HM Prison, Wandsworth. Fingerprints are synonymous with unequivocal identification, truth for which no alternative explanation can be accepted. The truth matters for criminal law.
[Stratton masks. Courtesy of The Line Up website. Article & image: Robert Walsh (http://www.the-line-up.com/).]
Tolerance of deliberate untruth corrodes a free society. We cherish free speech, but we cannot be indifference to deliberate falsehood. Just as evidence replaces dogma with verifiable information, deceitful claims must be challenged by testable facts. Few have expanded on this topic with greater clarity than Harry Frankfurt, although it seems that misdirection of facts is becoming more prevalent. [Frankfurt. On Bullshit. Princeton University Press. 2005.] Propaganda, lies, and plagiarism fall are breeches of the important social norm of truth and should irritate us enough to call them out as learning opportunities so we can learn how to recognize them, understand how they corrode professionalism, use them as teaching opportunities, and reaffirm one's own standards.
Not every crime has its fingerprints, but just as the internet offers plagiarists opportunity to harvest cyberspace, the internet gives readers strong investigative tools. Science magazine earlier this year dedicated an issue to the matter of how evidence should inform public policy and contained an introduction to the discussion called "A matter of fact" by David Malakoff [Science 355:563, 2017].
"This is a worrying time for those who believe government policies should be based on the best evidence. Pundits claim we've entered a postfactual era. Viral fake news stories spread alternative facts. On some issues, such as climate change and childhood vaccinations, many scientists worry that their hard-won research findings have lost sway with politicians and the public, and feel their veracity is under attack. Some are taking to the internet and even to the streets to speak up for evidence. But just how should evidence shape policy? And why does it sometimes lose out?"
What we take as facts or truth is susceptible to change or even error. In fact, evolution is built on error. Missense is the phenomenon in which a single nucleotide substitution (that is, a point mutation) changes the genetic code such that an amino acid is produced that is different than the one intended in the original genetic code. The ultimate protein built of the amino acids may be dysfunctional or nonfunctional as in the circumstance of sickle-cell disease where the hemoglobin beta change is changed from GAG to GTG. Random error, or perhaps "purposeful missense" from a creationistic point of view, is the mechanism of evolution and diversity.
We expect integrity in most transactions in society and we are justly offended when this expectation is not fulfilled. The privileges of professional occupations are based on their fulfillment of this public trust, and few professions are older or more essential than the health sciences. Error and imperfection represent the honest "missense" of humanity's work, but deliberate deceit is another story breaking a universal taboo.
Transgressions against the public trust are especially reviled in medicine and science. A spectrum of transgressions exists, from a casual moment of dishonesty all the way to fraud, theft, and other criminality. Plagiarism sits in the middle of the spectrum. Some plagiarism is merely poor scholarship, but most often plagiarism is out-right theft. Once someone falls into the plagiarism trap, it is difficult to distinguish among its variants. Self-plagiarism revolves around the repeating one's own work, but representing it as new. Of course, we all repeat our own ideas and words over time, but if you write a book chapter the publisher may claim ownership of your words, so you must be careful not to repeat wholesale your own paragraphs or illustrations in later articles, especially if the perception is to be that the newer article is genuinely "up-to-date." Still, this differs from the deceit of stealing someone else's work.
Scientific misconduct with deliberate plagiarism, fabrication, and falsification of data is a big problem, not so much in scale and prevalence – for I believe we have only occasional bad actors in our midst – but more because of their effect of distorting truth and corroding the public trust as an article in Science by Jeffrey Morris last year examined. [Morris. After the fall. Science. 354:408, 2016.]
Gaslighting. On May 4, 1944 MGM released a movie called Gaslight, starring Charles Boyer, Ingrid Bergman, Joseph Cotton, May Whitty, and Angela Lansbury. The story, based on a 1938 Patrick Hamilton play, concerns a woman whose husband manipulates her into believing she is insane in order to distract her from his criminal activities. One of his deceptions is causing gaslights to flicker, making his wife think her vision is unsteady. Fiction became reality as the gaslighting metaphor found use in everyday speech for forms of manipulation through denial, misdirection, contradiction, and outright deceit to delegitimize or destabilize a target. Florence Rush (1918-2008), an American social worker and feminist theorist, applied gaslighting in her work as a pioneer in studies on childhood sexual abuse. (She also introduced the concept of the sandwich generation.)
Plagiarism is one form of gaslighting, the deception being the authenticity of ideas, statements, or evidence. The assumption of truth is a bedrock expectation in healthcare. Once abused, trust is rightfully difficult to restore. For example, the trainee who fudges a laboratory report during rounds may momentarily escape with the untruth, but the intoxicating bad habit gets repeated and ultimately discovered. The same goes for plagiarism or overt research fraud, where the likelihood of discovery increases exponentially over time because perpetrators invariably repeat the offense and the longer the evidence sits in public space, the more likely it will be recognized for what it is.
Paul Simon's 1986 song, All Around the World (The Myth of Fingerprints), challenged the metaphor of universal individuality with a great tune, but a cynical lyric. Steve Berlin of Los Lobos claimed that Simon never gave the band due credit for the music that they had previously created and played when helping Simon on the Graceland album. After the band saw "words and music by Paul Simon" on the album 6 months later, they contacted Simon who said "Sue me, see what happens." They didn't. [Chad Childers. Rock Cellar magazine. July 23, 2012.]
Case reports. When I was medical student and resident, case reports were foundational parts of medical education, expanding the generalities of systemic and organ-based learning and offering personal stories of medical detective-work. Some case studies illuminated classic presentations of disease, others were exceptions that proved a rule, and some were exotic conditions that surprised and educated us. Case studies, coming from reputable sources, carried a sense of authenticity – they were accepted as true facts beginning with the earliest medical journals such as The Lancet. In time, with the emergence of technology, defined areas of study (the disciplines, departments, specialties) scientific method, and randomized controlled trials offered higher levels of rigor.
Case studies also provided many of us early chances to study an illuminating case, present at conferences, and even publish. Medical journals were once heavily dependent on case reports. Evolving technology added illuminating images to 20th century specialty journals. Whereas relatively few students and residents had access to million-dollar biologic labs or enormous data sets, any ambitious resident could find an interesting clinical story to expand upon and present.
In my early faculty years ivory towers began to sneer at case reports as journals marginalized and eliminated them. Hypothesis-driven research, sophisticated laboratory studies, clinical trials, and health services research dominate current medical journals. Electronic media by threatening the business plans of medical journals, have challenged their very purpose and identity, leading many publications to retreat to imagined core functions or pander to readership surveys that represent very weak science themselves.
A few journals have, however, maintained a place for single case stories or recently restored them. Case reports are a renewed feature in The Lancet. That journal and JAMA also embrace art, commentary, and relevant news that expand their interest for many readers. A recent paper in Academic Medicine, gives a strong argument for the educational value of case reports. [CD Packer, RB Katz, CL Iacopetti, JD Krimmel, MK Singh. A case suspended in time: the educational value of case reports. Academic Medicine. 92:152, 2017.]
I don't think I'm so different than most of my colleagues in wanting medical journals that curate relevant facts and issues broadly. Anything related to sustenance of the human condition from our medical perspective should be fair game for our journals including new evidence, ideas, technologies, therapies, understanding of health and disease, environmental threats, controversies, health care economics, educational matters, medical humanities, and art. Focus and balance is necessary for editors and boards, but the strong journals of our times (The Lancet, JAMA, NEJM, or Science, for example) seem to get it pretty much right for their readerships.
What Archie Cochrane learnt from a single case was the title of a recent article in The Lancet in its recurring section called "The art of medicine." [Brian Hurwitz. The Lancet. 389:594-595, 2017.] The title of the article is ironic given that this Scottish physician (1919-1988) had extraordinary belief in randomized controlled trials that led to the Cochrane Library database of systematic reviews, The UK Cochrane Centre in Oxford, and the international Cochrane Collaboration. Yet, there in The Lancet, I found this article on what Archie learned from a single case. An illuminating single case can be a powerful tool, in medicine, in the broader scope of journalism, and in political speeches. Ronald Reagan was probably the first US president to use this tool in public addresses, as for example in the Pointe du Hoc speech in 40th year anniversary of D-Day at Normandy on June 6, 1944, when he alluded to stories of a leader (Lord Lovat), a bagpiper (Bill Millin), Canadians, Poles, US Army 2nd Ranger Battalion solders shooting ropes up over the cliff face, as well as Americans back home ringing the Liberty Bell in Philadelphia, going to church at 4 AM in Georgia, or praying on porches in Kansas. Reagan (and speechwriter Peggy Noonan) understood the specific instance of a particular story illuminates a much larger reality.
Scientific experimentation, including the randomized controlled trial, offers a high level of rigor and verifiability in accruing new knowledge, and largely has replaced stories of individual clinical experiences, however the work-in-progress of medical education shouldn't be so highfalutin as to deny entirely the value of carefully-presented case studies
New rules. Last month we held a retreat for faculty, residents, and advanced practice providers (pictured above and below at Michigan League). We heard ideas and facts from Vice Deans David Spahlinger and Carol Bradford, along with strategic plans from our divisions and associate chairs who oversee the components of our missions. It became clear that our department is nearly the right size for our mission and obligations, although we will need about 10 more FTEs over the next 3 years to reach and maintain that size. Mission, essential deliverable, markets, professionalism, and work-life balance were discussed. My term as chair will come to a close and we expect to announce a search committee this summer. Once replaced, I hope to remain on the faculty in a meaningful way for a few years just as did my predecessors Ed McGuire and Jim Montie. Jim, by the way, was unable to join us due to grandparenting privileges keeping him in Europe at the time, but he sent a short and inspiring video that explained how "culture eats strategy." Jim's ten pieces of advice, slightly rephrased below, for academic medicine ring very true.
a. Faculty have a higher purpose other than personal success; academic success is not a "win at all cost" endeavor. Academic medicine is not the Hunger Games.
b. Expert and empathetic clinical care is the highest priority.
c. Urology's culture is embraced and preserved by faculty and inculcated in fellows, residents, and staff.
d. We share respect for colleagues, fellows & residents, and staff.
e. Academic productivity is important.
f. Referring physicians are highly valued and respected.
g. Try to make UM better, even at some sacrifice.
h. A team is necessary and one with diverse thoughts and backgrounds is always better.
i. Salary should be sufficient to that ensure faculty are not being taken advantage of (actually or perceived).
j. Innovation is the lifeblood of outstanding academic medicine.
Jim called his list "Thoughts for living in Michigan Urology." He also added a question for the new paradigm of Michigan Medicine: "How does Michigan Urology integrate UM affiliates into the Urology Department? Don't wait for the institution to solve it. Decide what vision you have and move to implementing it. Get to know the people at these other hospitals and practices."
These are our thoughts for May, a month in which the redbuds have been amazing in and around Ann Arbor.
Posted in Academic medical center, Graduate medical education, History, Maize and Blue, Medical education, Medical humanities, Nesbit Alumni Society, Spring, Uncategorized, University of Michigan, University of Michigan Health System
April facts
DAB Matula Thoughts April 7, 2017
April facts – mischievous & urological
April, the first 30-day month of the year, opens up the northern hemisphere spring with welcome visibility of diverse flora and fauna. It should surprise no one that the diversity of life sustains all life on the planet and loss of that diversity imperils everything. A multitude of critters share our space and today it is the wombat that comes to my mind. Australian newspapers The Sydney Herald and The Age reported a wombat attack this day in 2010 when a man named Bruce Kringle ended up in the hospital after mauling by the marsupial. The worldwide British Broadcasting Corporation quickly picked up the news. These sizable animals average over 3 feet and 60 pounds as adults. [Photo by JJ Johnson. 29 November 2009. Taken at Maria Island National Park, Tasmania.] Territorial infringement was likely in play in this instance, as the victim was living in a camper when he stepped out the door and encountered the angry wombat, unusual behavior for the animal and ultimately self-destructive after Kringle found an ax and made short work of it on this summertime February day in Australia.
The Wombat coincidence this day on this April day piqued my interest, because in a previous April, 1998, the British Journal of Urology (BJU) published an article on wombat uroflowmetry. [D. Johnson. Case report. Observations on the uninhibited bladder of the common wombat. BJUI. 81:641-642, 1998.] For those readers uninitiated regarding matters of scientific micturition, uroflowmetry is the measurement of the flow rate of urine during the process of emptying the bladder. Mankind is naturally curious about its personal byproducts and inspection of sputum, urine, feces, etc. has offered clues to understanding disease since the times of the earliest healers. Of course most mammals have olfactory interest in their own urine and that of others, as evidenced in the canine world. Uroflowmetry provides true facts about urination, thanks to our ability to measure time and volume, as well as understand velocity.
My interest in uroflowmetry preceded the wombat stories and goes back to Walter Reed Army Medical Center where my chief, Ray Stutzman, introduced me to the concept of timed uroflowmetry and we wrote a paper comparing it to instrumental uroflowmetry. [J. Urol. 133:421, 1985] I then wondered about uroflowmetry in other species and the elephant seemed a good place to start. Discussion with the elephant-keeper at the Washington National Zoo taught me something about pachyderm urologic habits, but we never completed the project, mainly because of a difference of opinion on the distribution of the tasks required by the methodology. Timed uroflowmetry requires a collection device and a stopwatch to measure the volume during 5 seconds of mid-flow. All of the elephants at the Washington Zoo at the time were female and their streams therefore required a collection device both large in volume and wide in aperture– basically a big bucket. The unpredictability of elephant micturition required someone standing in place with the bucket. Since the uroflowmetry idea was mine and the elephant-keeper was on better terms with the pachyderm than I was, it seemed reasonable for me to hold the watch while the other guy held the bucket. The elephant-keeper disagreed with that assignment and claimed the stopwatch. Given that stalemate, the study has yet to be performed and awaits an ambitious medical student or resident, or a more flexible elephant trainer.
Another elephant crossed my path around this time of year after Ed McGuire brought me to Michigan. A child with gross hematuria presented to clinic with her grandparents and we diagnosed urologic malignancy. After surgery she remained in hospital for further treatment and by this point the parents had come to town. They were circus people and owned a number of animals including a young female elephant. Domino's Farms graciously allowed the family to camp out on their property for the weeks of therapy, and one spring afternoon the child's family invited our pediatric urology team and kids for elephant rides.
Planarial detour. Scientists crave facts and know their job is to ferret out true facts. Bill McRoberts, colleague in Kentucky, friend, and our third Duckett Lecturer at Michigan used to tell his residents "a little fact trumps a lot of myth," an idea parallel to Coffey's advice to trainees: "you have to understand the difference between facts and true facts." Evidence, analysis, and experiment are the ways we come to verifiable truths and enduring realities that constitute true facts. While all biological creatures deal with facts of their environment, many facts are only transient realities. A planarium, for example, may sense that its world is 20°C and that food is available straight ahead of its momentary motion, but those facts may change quickly. We humans can examine myths, discover momentary facts, create hypotheses, and perform experiments in search of something we call the truth, an aspiration we think is unique to our species.
Planaria, by the way, are among the simplest animals to manage their waste with a dedicated excretory system. Paired flame and tube cells ending in a pore assemble as protonephridial tubules along the length of the flatworm. These are capable of regeneration. [JC Rink, HT-K Vu, AS Alvarado. The maintenance and regeneration of the planarian excretory system are regulated by EGFR signaling. Development. 138:3769, 2011] Planarial flow rates could be a topic for a future study. More practically, the mechanism of planarian excretory regeneration could be turned to human renal replacement therapy, thus proving the point that today's obscure fact may be tomorrow's revolutionary insight.
[Above: planarian Dugesia subtentaculata. From Santa Fe, Montseny, Catalonia. Wikimedia Commons. Eduard Solà.]
[Above and below: reproductive and excretory systems of flatworm. Source – Wikimedia Commons, Putaringonit.]
When the wombat uroflowmetry paper in the BJU caught my attention in 1998, I suspected a prank, something not unknown in British medical publications, particularly around the month of April. Thinking a clever reply might be appreciated by the journal, I resorted to limerick form in a letter to the editor, Jeff Chisholm. Surprisingly, my letter was published and now constitutes the only "poetry" of any sort to find its way into my CV. [DA Bloom. Re: Wombat uroflowmetry. BJU 83:365, 1999.] Chisholm annotated my reply: "Edited versions – apologies to the author!" The annotation was in this limerick:
"Lo, the wombat – it all must be true
So free when it's not in the zoo
Pees lots when it poops
By well-used neural loops
As told in the new BJU"
Pranks, myths, and propaganda veer from the true facts attended to so carefully in our professions. Last spring, sitting in on the class my daughter Emily, assistant professor in English, was teaching at Columbia University I heard her challenge a familiar myth with data from a paper in Science. [Mehl. Science. 317 (5834): 82, 2007.] The myth was that women spoke more than men, and observation of my children and grandchildren still supports that idea. The thing about myths, however, is that they usually short-circuit our best efforts to think critically. Appealing to the lazy tendencies of our brains, they get an easy pass for "truth." Although I subscribe to Science, I had missed that particular article (and likely hundreds of other important ones since then). Matthias Mehl, associate professor of psychology and author of the paper, studied 210 women and 186 men with a voice-activated device that captured 30 seconds of conversation every 12.5 minutes (5% of the day) and found that women used 16,215 words and men 15,669 words daily – no significant difference. One might argue that possibly women used longer words for more complex conversations, and inspire another study. Another question, also heavily dependent on educational, socio-economic, and occupational levels of subjects tested would be how many words does "an average person" hear every day? It is likely that fewer words are actually comprehended than spoken.
Word count interests me in relation to this monthly column, What's New/Matula Thoughts. Approaching 4000 words it offers a substantial amount to read, a quarter of what most people speak every day. It is surely vain on my part to think that the general readership consumes all these words critically, although a few friends read this more carefully than I write it. My point in writing, however, is that it fills some fundamental personal need to communicate beyond the simple necessities of survival and daily work, the need that our distant ancestors (Homo sapiens, Neanderthals, and their hybrids) fulfilled some 30,000 years ago on the walls of their cave dwellings. These particular electronic postings you now read are hardly so novel, artistic, or durable.
More on words. Considering a career in urology a medical student at Pritzker Medical School in Chicago, Logan Galansky, recently contacted me for advice and as she explained her previous work in hearing and learning she described the 30 million words idea – the hypothesis that children who heard that many words by age 3 years had a lifetime advantage over those who were exposed to much less. [B Hart & T Risley. (2003). The early catastrophe: The 30 million word gap by age 3. American Educator, 27(1): 4 – 9.] Complicating any easy assumptions, however, is the fact that the study compared children from "professional families" to children from "impoverished families" in Kansas City, KS in the 1960's where other confounders beyond experiential words were at play. The pivotal study involved 42 families that were divided into 4 socioeconomic groups. Although scrutiny detracts from the easy conclusion it certainly is plausible, if not likely, that richer vocabulary experiences build more robust vocabulary inventories, and those inventories are an advantage in life.
Our Department of Urology Faculty Retreat next week is a sort of spring training for the next decade of urology at the University of Michigan. Each clinical division and key domain, such as education or the Dow Health Research Division, will present strategic visions. Individual faculty have updated their web profiles and we should get a pretty good sense of ourselves as an organization today and what we hope for in the intermediate future. How many words will be spoken at this retreat? Given pauses, breaks, and other interruptions, and assuming a leisurely rate of 100 words per minute (130-150 wpm may be more typical of conversational speech) over 5 hours we may hear 30,000 words. Who knows what will stick or what people will take away, but I hope we will align around our mission and that we will understand our divisional strategies and visions of the future.
Disparities. Important lessons from Star Wars, observed by The Economist and mentioned here last month, bear repetition. First, economic disparities are inevitable in the galaxy, in spite of advancing technology. Second, although free trade advances economic growth, free trade will never benefit everyone equally; some "humans will still labor at dangerous and unpleasant tasks" because of inequities within political systems.
Society benefits substantially by mitigating disparities that, while inevitable in humanity, impede the common good. Society gains when its entire human capital is educated, productive, healthy, and kind. If only certain privileged subsets of its potential workforce have opportunity for education, employment, and productivity, then the potential of that society is diminished. A generation ago, scientific investigation of healthcare disparities was not high on the ladder of interest in academia, federal funding, or industry. This has changed greatly, and our Urology Department Dow Health Services Research Division reflects the new attention. An important paper in JAMA earlier this year looked at trends and patterns of disparities in cancer mortality by counties in the USA from 1980-2014 and the results relevant to urology are riveting. [AH Mokdad et al, corresponding author CJL Murray JAMA. 317:388-406; 2017.]
Prostate cancer:
Kidney cancer:
Testicular cancer:
The United States is a large and diverse country, but why people with specific diseases should have different regional disease frequencies, expectations of care, and survival is a complex question with many answers. Regional variations of disease frequency and survival can depend upon environmental factors such as air or water safety, occupational hazards, poverty, food safety, public safety, weather conditions, and many other factors that vary according to geography and socio-economic conditions. Looking at the maps we have to agree with Dorothy, in The Wizard of Oz, that the center of the country is a good place to call home.
Centrism. A cornerstone aspiration of American representational democracy is justice, opportunity, and dignity for all participants. This must be balanced against the centrist tendency inherent in majority rule of the electorate. Cosmopolitanism must be respected and those who are disadvantaged require a humane safety net. Life, liberty, and the pursuit of happiness are those basic Jeffersonian beliefs articulated in the Declaration of Independence, but even after more than 200 years they remain work-in-progress, complicated by a world that is rapidly changing in terms of socio-economic, geo-political, environmental, demographic, and technology factors.
The political center of the United States will always be a matter of debate, however the geographic center of the contiguous United States according to the US National Geodetic Survey is 39°50′N 98°35′W. This spot happens to be in Kansas, approximately 12 miles south of the mid Kansas–Nebraska border and 2.6 miles northwest of the center of the city of Lebanon. Not too far south and east of that point is Abilene, Kansas where Dwight David Eisenhower was raised.
Health care is unquestionably wrapped up in the idea of life, liberty, and the pursuit of happiness, and healthcare politics concerned most presidents even before the mid-20th century. Around that point in time the AMA position was that the federal government should not be involved in healthcare, while Truman favored national health insurance and Eisenhower sought legislation to support the healthcare insurance industry.
On April 16, 1953, twelve weeks into his presidency Eisenhower delivered one of his greatest speeches. This was just a month and a half after the death of Stalin and, as the president then knew, the first hydrogen bomb would be tested within a year (code-named Castle Bravo it was detonated March 1, 1954 at Bikini Atoll, Marshall Islands). Eisenhower saw an opportunity to reset the increasingly costly escalation of the cold war. The occasion was a meeting of the American Society of Newspaper Editors in Washington, DC. Eisenhower worried about the disparity between military spending and the spending of a nation on the life, liberty, and pursuit of happiness of its people.
"In this spring of 1953 the free world weighs one question above all others: the chances for a just peace for all peoples… "
No one dared remind Eisenhower that liberty required a robust and costly position of defense, but he was convinced that the escalating costs were not only excessive, but also realistically unnecessary. He believed that the nations of the world had reached a point where the worst that could be expected by the escalation was terminal nuclear war while the best hope was
"… a life of perpetual fear and tension; a burden of arms draining the wealth and labor of all peoples; a wasting of strength that defies the American system or the Soviet system or any system to achieve true abundance and happiness for all the peoples of this earth. Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed those who are cold and not clothed. The world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children."
He noted that the cost of one heavy bomber equated to modern brick schools in more than 30 cities, a single destroyer equalled a new home for 8,000 people, or a fighter plane cost a half million bushels of wheat. Inflation and technology have pushed the costs much higher.
The Nesbit Society and the AUA come to mind as spring approaches. The AUA originated in 1902 in New York City when urologist Ramon Guiteras felt the need to congregate with other urologists. Barely 17 years later his colleague Hugh Cabot in Boston, returning from WWI, began preparations to move to Ann Arbor attracted by the opportunity to organize a medical school and hospital system to suit the changing times of health care. Cabot's successor, Reed Nesbit, became the first head of urology at Michigan, presiding for nearly 40 years, followed by Jack Lapides. The Nesbit Society was formed in 1972 under the leadership of the Nesbit/Lapides trainee John Konnak, who by then had become a faculty member. The legacy of these great teachers and urologists is the Nesbit Society, now with 324 members. To a large extent, it is the Nesbit Society to whom this monthly electronic posting is directed (although a few members prefer a hard copy and Sandra Heskett graciously obliges). It is always a delight for me to hear from our Nesbit alumni and friends. John Hall (Nesbit 1970), for example, sent me this phrase that has informed his practice throughout his excellent career in Traverse City: "We don't practice medicine until we get it right, we keep on practicing until we will never get it wrong." Hall's Theory of Medical Education, like the Hippocratic aphorisms, distills wisdom into a phrase that you can carry around and re-inspire yourself when the going gets rough on a given day in clinic or operating room. This is one of the ways good professionals inoculate themselves against burn-out.
The Nesbit Society meets twice a year: once during the AUA national meeting in Boston this year on Sunday May 14 and all Nesbit members and friends of the department are welcome. The second occasion is our alumni weekend here in Ann Arbor September 14-16.
Most species congregate and the chairs of our academic departments do this with some regularity. I came across this picture of such a congregation 3 years ago in April when Mike Johns was interim EVPMA. This particular dinner was at The Earl, and the picture was taken before everyone had arrived, but it turned out to be my best picture of the evening. [From left: Karin Muraszko, Valerie Opipari, John Voorhees, Mike Johns, Carol Bradford, Reed Dunnick.]
The clinical departments are where the rubber meets the road in carrying out the missions of our UM Health System mission. Departments have been the building blocks of universities for hundreds of years, and academic medicine departments have effectively educated their successors, expanded the conceptual basis of their fields, and performed the essential transactions of clinical care over the past century. The clinical mission is the milieu for education and research as well as the financial engine for academic medicine. The changing economic, regulatory, and technological environments threaten the delicate balance of that mission. At Michigan our ambulatory care unit (ACU) model of delivering care has been successful, with the healthcare providers in central roles of making local operational general strategic decisions more effectively than management by managerial accounting methodology. This is largely the concept of lean process management. Clinical departments bring a third dimension of the academic mission to ambulatory clinics of providers and patients.
April, the cruelest month in the view of TS Eliot, can be mischievous and its first day, April Fool's, sets the tone. The origin of April Fools Day, may well have to do with April being the first calendar month of the year in medieval European towns when March 25 marked New Year's Day. April in Ann Arbor often brings mischief since a given day may be spring-like while the next might be wintry. That shouldn't be surprising, as nature routinely throws curve balls to test our fitness. Actually, yesterday afternoon I saw snow flurries from my office window and more snow last blustery evening.
[Above: April 2, 2016 at home. Below: April 13, 2016 Old Mott on left, Main Hospital center, and Taubman on left.]
Biology's astonishing diversity sustains our particular human biologic niche, yet ironically our very presence as a species chips away at biologic diversity and erodes our niche. This erosion has been going on for a long time and the angry wombat is only one tiny example. Its likely ancestor, the Diprotodon (meaning two forward teeth), was the largest known marsupial and a member of the Australian megafauna that existed from 1.6 million years ago until extinction around 46,000 years ago. That latter date coincides with the time our human ancestors were making their first cave dwelling paintings as they were eating the megafauna. Koalas and wombats are, perhaps, miniaturized surviving versions of the rhinoceros-sized Diprotodon. The wombat's dental plan facilitates its Darwinian niche, allowing it to tunnel forward vigorously. Cleverly, its marsupial pouch opens retrograde, to avoid collecting dirt as it burrows. After 3-week gestations, the young live in the pouches for 6-7 months, but still do not wean until 15 months of age. Wombats have no tails and their tough rear hide is cartilaginous most posteriorly, making it resistant to predators. Wombat scat (below) is oddly a nearly perfect cubic form, somehow resulting from its peculiar physiology. Wombat groups are variously called wisdoms, mobs, or colonies. [Wikipedia facts, Photo JJ Harrison]
As the environment changes, you never quite know what to expect each day going forward. One value of knowing some history is that it gives you a little confidence of what to expect. For example, if you know the earthquake history of your location has a frequency of once in a millennium, with the last recorded 100 years ago, you might reasonably conclude that it is safe to live there. More immediately, if the sidewalk you are about to traverse is riddled with pigeon droppings, you might cross the street to walk on more auspicious pavement. When Bruce Kringle woke up 7 years ago in Australia, he certainly had no idea that an angry wombat was going to take him on when he stepped out of his mobile home, although had he examined the ground he might have recognized its unique cubic scat.
[Wikimedia Commons: Bjørn Christian Tørrissen. http://bjornfree.com/galleries.html.]
Postscript. John Barry, in response to the picture of the Olds 88 last month wrote: "Looks like a 1951 Oldsmobile 88 K-body 2 door sedan with a V-8 engine and a Hydramatic transmission. I had one when I was a senior in high school. Great car. I used to buy cars, fix them up and resell them from my parent's driveway.
Thank you for reading Matula Thoughts this April, 2017.
Posted in Academic medical center, April Fools Day, Medical humanities, Nesbit Alumni Society, University of Michigan Health System, Wombat