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.