Putting the Puzzle Back Together


S.Q. Lapius dressed in bathrobe and green eye-shade was hunched over his desk poring over the array of papers, and scribbling notes.  From time to time he would open bound issues of medical journals and leaf through the pages till he found the reference he was looking for, then jot some more notes.  As if this weren’t enough he would pad over to the bookshelves in his sheepskin bottles and pluck another volume to search an index.  This was a ritual that occupied him at least two evenings of every week.


“How many publications do you have now, Simon?” I asked, when he paused for a break.


“I haven’t counted them Harry, forty or fifty.”


“Not bad for a man in practice, considering that you have to borrow the time from your spare moments.”


“Of course you realize, Harry,” Lapius said, “that now I write mostly case reports.  In my younger days when I was doing clinical research the articles I wrote had more substance.  Of course that was my job then so I could attend to it during working hours.  But the papers were more complex, of course.  I like to think they comprised a contribution to the medical literature.”


Lapius had great reverence for the medical literature.  “It is our thread to the past,” he would say, “our link to our medical forefathers.  The medical literature expresses the tradition of medicine, and reflects the increasing advance of science into the art of medicine.  It is quite fascinating.”


“And hard work as well.”


“Of course, but what a learning process.  There’s nothing to equal the exhilaration when the pieces of a puzzling concept fall into line and you find the words to express it.  Really, you should write more than you do, Harry.”


“I haven’t the time,” I said.


“Ridiculous, my boy.  Of course you do.  That’s a lame excuse.”


“It might have been a few years ago, Simon,” I said, “but if you would take your nose out of the books for a few days you would find out that you are supposed to prove that you have several hundred hours of approved medical education every so often, or else you are threatened with loss of licensure, or a recertification examination.”


“You are spoofing,” Lapius said, as he turned back to his books.


“Not a spoof, Simon.  A fact.  If you don’t demonstrate to the satisfaction of the examiners that you have attended the required number of approved conferences your career is at stake.”


“No!  Where did you read that nonsense?”


“No nonsense – well, I agree it is nonsense, Simon,” I explained, unable to believe that this crucial demand on the doctors’ time had escaped Lapius, “but nonsense or not, it is a fact.”


Lapius stared at me his eyes, peering over his glasses perched on his nose, reflecting the green of his eyeshade.  “What imbecile concocted that business?” he inquired.


“The imbeciles in the legislatures of most of the states of the Union,” I answered.  “It may even come to pass that unless a doctor is deemed qualified according to the latest educational demands, that Medicare will refuse to authorize payment to him.”


“What pompous presumption is that.  And who qualifies the legislators to make such rules.  Who is to tell me what is and what is not educational?  Certainly I have sat through some of the dullest lectures by ill-informed dolts that the state society sends around to meetings to lecture on specialized subjects.  Some of them are preposterous, ill-prepared, projecting illegible lantern-slides to illustrate subject matter that they soon demonstrate is foreign to them.  Is that supposed to be the education we are required to feed on?  And how many credits will I get for all the study that goes into writing one of my papers?  How many credits will I get for scanning the medical journals at my bedside, for the hours I listen to medical tapes, for the forty years devoted to hospital rounds, emergency care, office practice, each moment of which represented a new learning experience?”


“Well, there is one way to get out of it.  You can join a medical faculty.  The assumption is that professors are keeping up with the new things, so they are exempt from recertification.”


“Ha, ha, that’s a laugh.  Professors these days are young fellows, addicted to the new.  I’ve been around too long to be taken in by that.  Sure they are bright, but also sequestered, hidden from the main-stream of human problems.


“If my years in medicine have taught me anything, Harry, it is that although the causes and treatment for disease keeps changing, the disease itself remains the same.  Why, when I left the faculty it took me several years to get my feet on the ground, to learn to stop treating disease and to start treating people.  I don’t see why faculty members should be a protected species, unless of course, it is they who will make up the tests that will be used to recertify us poor commoners.”


“That’s the idea,” I told him.


“Well, then more is the pity then, Harry.  The more things change, the more they are the same.  Our leaders will pass on our qualifications, but who then will pass on the qualifications of our leaders?  Anyway, it’s time for me to get back to work, so if you will excuse me-.”


“So you won’t enter into the spirit of the thing?”


“Presumptuous ‘gobbledegook!’  I certainly won’t give up precious hours to an educational program prescribed for me by someone else.  I will just continue to do what I and generations before me have always done.  Attend to the business of medicine; which means attending to my patients, puzzling out conflicts in diagnostic facts, reading the medical literature, and reporting what I believe will be helpful to others.”


Lapius turned his back to me and resumed his studies.  The dialog was ended.*


*Progress in medicine has accelerated a hundred fold since 1975 and continuing medical education has become a necessity. The initial judgment of Lapius was wrong-headed. The hated bureaucratic leadership was appropriately farsighted.