Dr. Charles Harris |
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LAPIUS
Introduction
In 1975 Harper and Row published my book One Man’s Medicine populated by two major characters, Simon Quentin Lapius, and Harry, the former senior and wiser than the other. The pair and settings were obviously borrowed from Rex Stout’s detective stories that paired Nero Wolfe who did the “thinking” for the firm, and his subaltern Archie who did the leg work.
S. Q. Lapius a homophone of Aesculapius, son of Apollo, father of Panacea and Hygeia. Aesculapius cured so many patients that Hades was being depopulated. Pluto complained about this to Zeus who palliated him by killing Aesculapius with a thunderbolt. After his death this venerated physician was worshiped and elevated to the pantheon of Greek Gods as the God of Medicine.
The homophone was misunderstood by most lay readers, who often approached to ask “Nice book but who is this guy Lapidus?”
After the book was published I continued to write brief vignettes about medical and other topics between 1973-1975 in the Lapius format. They are pertinent to medical issues being discussed today.
Here they are 300 pages worth.
When edited down they will make a handsome interesting easy read of opinionated dialogs on medical topics that will be of interest to every one who has visited a doctor or paid for health insurance recently—probably about 150 million people.
And I can write sequels about medical practice 2006
Safety--Testing Drugs on Children Daily Observer March 29, 1973
Lapius was supine on his commodious recliner picking through a stack of medical journals and throwaways at his side, and I lay on the couch trying to glean the Sunday Times. Suddenly he started to chuckle, interrupting my concentration. Had the situation been reversed he would have imperiously ordered me from the room. I ignored his laughter, and was working my way back into the column when he said, “The Food and Drug Administration has worked itself into a corner.” “How?” I asked, without taking my eyes from the page. “They’ve become so stringent about testing new drugs before allowing them to be sold to the public, that they may be depriving a large and deserving portion of the public from receiving important medications.” We were going to have a conversation whether I liked it or not so I put my paper aside. “How so?” I asked. “Well, as you know, Harry, every new drug has to work its way through animal testing, in both acute and chronic experiments, and finally there should be a clinical trial as to efficacy. To do this they give samples of the drug to duly licensed physicians who then mete them out to volunteers, and record the side effects if any, and the good they do, if indeed they do. But they have no way of testing children, so they can’t properly permit some of these substances to be administered to children.” “Why not?” “Because a child can’t legally volunteer to be a subject for experimentation, and it’s not likely that a parent would grant permission for a child to enter such a program.” “But if the drugs are ok for adults, surely in smaller doses they would be ok for children, wouldn’t they?” “Who knows. There’s no way of finding out. After all, children are at a stage of rapid growth. Each of their body cells is the forerunner of many generations of cells that they will be made of when they are adults. Thus in a child if you genetically alter one cell, you may be causing genetic damage in thousands of future daughter cells, whereas in an adult, damage to one cell isn’t so serious.” “Do you believe that?” “Not entirely, but who can tell. Anyway, I enjoy their predicament. They’ve become a bit pompous, the Food and Drug boys. You know, there are many drugs on the market now that can be used for diseases for which they are not approved. This has been shown by doctors in many clinical trials. But if a doctor tries one of these for a purpose not specifically stated in the brochure that accompanies each drug, and if it causes side effects, the doctor might have a hard time defending himself in a malpractice suit. “That’s ridiculous.” “Of course it is.” “What’s the doctor suppose to do?” “Perhaps when the situation arises when he feels he must prescribe something not specifically authorized, the doctor should take the patient into his confidence and explain the possible benefits and risks, then have the patient sign a waiver.” “A sticky wicket.” “To be sure. It’s another example of a third party interfering with the doctor-patient relationship. The doctor has sole responsibility for the patient, but the third party takes over some of the authority for the care of the patient.” I was getting steamed. “That’s terrible. I think something should ---.” Lapius shut me up with a wave of his arm. “That’s enough prattling now, Harry. Get back to your funnies. Can’t you see I have important work to do?”
British Medical Journal and Freedom of Press Daily Observer April 5, 1973
Lapius was busy underlining passages in the journal that lay open on his desk. “Something must grab you, Simon. I haven’t seen that since I was a medical student.” He chuckled. “Chalk one up for the British Medical Journal. A landmark case, and possibly an omen of things to come.” “Why what’s going on across the briney?” “An attempt at suppression of the fourth estate, the medical fourth estate no less. You know the newspapers of late have been full of remarks by Whitehead, of the Nixon administration, and Agnew before him which many have interpreted as attacks on the news media. But to my knowledge there has never been an attack on the freedom of the medical press. Yet, one such appeared in England.” “You mean someone has threatened the freedom of the British Medical Journal to publish what is sees fit?” “Precisely, Harry.” “What do they publish that’s so threatening? Some scientific articles, a few case reports? What happened? Did they latch on to a new Andromeda strain? Did they unwittingly expose the militaristic implications of the London Flu? Is Scotland Yard breathing down their necks?” “Nothing so flamboyant, my boy, but serious nonetheless.” “I can see someone trying to liven the old girl up a bit. A few cartoons from Punch, a few columns from the Village Voice, but who would want to suppress anything that the British Medical Journal hopes to publish? “S.L. Drummond-Jackson, for one, Harry. It seems that he is a practicing dentist who advocated the use of a new anesthetic procedure for dental surgery. The subject was examined by scientists who concluded that the anesthesia had side effects which may well have been the cause of a number of deaths, and published their results in the British Medical Journal. I guess old Drummond-Jackson felt that this sort of publicity would be detrimental to his practice, so he sued the authors of the article as well as the British Medical Association. He demanded that the British Medical Journal publicly renounce its position and undertake ‘not to publish any similar statements in the future’.” “Had they slandered old Drummond-Jackson in print?” “That’s the strange part of it. It was a completely objective article evaluating the worth of the anesthetic on the basis of the facts at hand.” “Well then S.L. Drummond-Jackson hadn’t much of a case.” “Of course not, Harry. But you don’t need a case to go to court. Taking someone to court is like a game of chicken, a bullying tactic. If the defendant backs down and settles out of court it’s been worth the effort. That’s the basis of many malpractice cases. The threat is enough to force a favorable settlement. But the British Medical Journal, made of sterner stuff, fought the case in court. It was a long, drawn out affair, and even with all their resources, S.L. Drummond-Jackson fought them to a standstill. The case was so costly that at one point one party or the other insured the life of the presiding judge in case his death caused a mistrial.” “Well, I see the British Medical Journal is still sailing under its old masthead, so they probably made out okay.” “Barely. On October 31, 1972, the adversaries decided to discontinue the action, and made the following statements: ‘The Defendants all recognize and acknowledge that the plaintiff is a man of the highest integrity and skill and of outstanding ability as a dentist.’ “Note Harry, they say nothing about him as an anesthetist. Then the Plaintiff made a statement: ‘The Plaintiff for his part withdraws any allegation against the defendants or any of them of dishonesty or impropriety. Further, he recognizes and acknowledges that the British Medical Journal has the right and duty to its readers and to the medical profession generally to publish articles such as that submitted to them by the individual defendants, and to comment on them.’ “Clearly a victory for freedom of the medical press and for the British Medical Journal in particular.” “Yes, Harry, they must have made some strong points to squeeze that statement out of Drummond-Jackson, but it seems dangerous precedent. Hopefully, if any other such cases arise the respective medical journals will show the same gumption as the British Medical Journal. Otherwise we’ll be reading what the Drummond-Jacksons and the advertisers would have us read, rather that the free selection of scientific articles chosen on their merit.” “Incidentally, Harry, how are you coming with that paper you are writing?” “Just fine, Simon. Incidentally, would you do me a favor?” “What is it my boy?” “I intend submitting it to the Archives. You have some drag with the editor. Would you write him a letter on my behalf?” I didn’t realize how strong Lapius was. He had me by the scruff of the neck and was hustling me to the door. “I don’t know whether to throttle you or leave you out with the cats,” he growled.
3Legal guardian Daily Observer April 19, 1973
My receptionist announced that Dr. S.Q. Lapius had arrived. I told her to send him in. Snow was melting on his collar, and when he doffed his astrakhan lamb’s wool hat that Gumbenich had sent him from Moscow a shower of snow settled on the carpet. “Sit down, Simon, I’ll only be a minute,” I said. “Don’t tell me I have to wait till you finish all those insurance forms, Harry. We’ll be here all night. You know I have a chess match later. Have you forgotten why I’ve come over?” “No of course not, Simon.” “Well then, where’s her chart?” I looked at him blankly. “Of course you’ve forgotten. I want to go over the case I sent you today. Dr. Burton’s mother, Jennie Burton.” “Simon, let me ask you a question. How did you come to refer that case to me?” “Burton called me this morning and asked if I knew an understanding young doctor who could help his mother. She has, it seems, a variety of medical problems, and Burton is concerned. So of course I mentioned your name.” “Quite a case.” “Interesting?” “Very.” ”Can you help her?” “Not a chance.” “Really? That serious? Goodness, what shall I tell poor Burton?” “Tell him that he should stop minding his mother’s business.” “Harry you’re acting very strangely. You must have had a difficult day.” “Sure it was difficult. Burton brought his mother to the office. She is leaning on two canes when the nurse escorts them to the examining room. I take a history and Burton answers all the questions. The old lady never opened her mouth. I thought maybe she was hard of hearing. Then I ask Burton to leave preparatory to examining her, and called the nurse in to help the woman out of her girdles, corsets, and ace bandages, an effort that has to take at least ten minutes in each direction. As soon as the nurse goes to help her, she lifts her cane and says ‘don’t come near me, I don’t want to be examined.’” “I said, ‘there must be some mistake, Mrs. Burton, your son the doctor, made the appointment.’” “’Good, she says, then examine him. I don’t want no examination. I’m all right.’” “’But your son says you are not all right.’” “’Shows you what kind of doctor he is,’” she says. Then she picks up the cane again and says, “’if you touch me I’ll scream.’” “I figure I better talk to Burton. He was in the waiting room. ‘Look here, Burton,’ I said, ‘your mother is kicking up her heels in there. She won’t let us examine her.’” “Burton says, ‘But she’s sick. She’s even a little senile. She doesn’t know what she’s doing. Go ahead and examine her.’” “’Are you her guardian?’ I ask him.” “’No of course not. I haven’t declared her legally incompetent. But she is nevertheless.’” “’You know quite well, Burton, that if I touch her against her wishes it constitutes an assault. Take her home. You have a legal problem to settle before you can settle your medical problems.’” “Well, Harry,” Lapius, said frowning, “of course you were correct. I’m sorry I got you into that. I didn’t realize what the situation was. But it seems that once people reach a certain age and develop a certain level of infirmity, their children assume a guardianship they don’t legally possess. They reverse the generations.” He paused and brooded for a moment. “I’ll bet this problem will play havoc in some of these geriatric hospitals. For example, say that there is an old lady, senile, with a sudden gall bladder attack. She requires surgery. The hospital calls the nearest of kin who signs permission for surgery. There are complications. A son in Chicago finds out about it and sues because his sister hasn’t the legal right to sign permission. Or if they hospital gets the patient to sign permission, the son in Chicago may sue on the grounds that his mother is non compos mentis and not qualified to sign. Too often we assume powers we don’t really possess.” “So what’s the answer, Simon.” “Not all problems have answers, Harry.”
About 10 years after this article was written I had a patient 90 years of age who needed a pacemaker. She was mentally intact, but insecure, and instructed me to talk to her daughter about the problems she faced. I spoke with the daughter and explained the problem and the need for the pacemaker, and how simple a procedure it was. The daughter nodded. I subsequently returned to the patient requesting that she read the “informed consent” and sign permission for the pacemaker.. She refused and said her daughter would take care of all these matters. The daughter refused to sign the documents. During the time that passed while I was searching for another relative, the patient died. When I accosted the daughter to demand why she refused permission for her mother to have a pacemaker she said, “I have been caring for her my entire adult life. Now I am seventy years old. I need a life too!” 4Dr. Welby, and Patient Care Daily Observer April 26, 1973
“Simon,” I called in to the living room. “The taxi is here.” “Tell him to wait; I’ll be along in about half an hour.” “How can I get him to wait half an hour?” “Give him five dollars.” I did. The cabbie turned off the motor and relaxed with a cigarette. I shed my coat and returned to the living room. Lapius was glued to the tube. There, Robert Young was impersonating a doctor and Lief Erickson was impersonating another doctor, and people were impersonating nurses, orderlies, receptionists and patients. “For goodness sake, Simon, we’ll be late.” He waved me to silence. “It will be over shortly.” I went into his study and buried myself in the latest New England Journal of Medicine. I became lost in an interesting article when Lapius came lumbering in, “Harry,” he called sharply, “stop dawdling, we’re late.” I suppressed some epithets and struggled back into my coat. Seated in the back of the cab, crushed between Lapius and the side of the vehicle in a seat that was built for three, I groused. “What’s the sense of going now? The lecture will be over.” “We’ll be in time for the refreshments, Harry.” “I guess you were a great soap opera buff too. Always late for dinner. Couldn’t tear away from ‘John’s Other Wife, or Melody Street!’” “As a matter of fact, I was. I always enjoyed these slice of life episodes. Show me a great novel that deals with the subjects of soap operas. Oh, once in a while there is a story about tuberculosis, but its tragedy is recessed into a plot. But the soap operas are about real life. So is Marcus Welby. No, Harry. I believe that the great tragedies, the nitty gritty things, are life and death matters. What is more dreadful than a member of a family developing a brain tumor? These catastrophes are so poignant that the great writers haven’t the art to deal with them properly. Look what happened to poor Erich Segal with ‘Love Story’. He became the laughing stock of the intelligentsia as being camp, kitsch, maudlin and other unkind descriptions. Yet the public loved it. Why? Because they could identify with the tragedy.” “But it’s so obvious and unsubtle.” “Of course. What is subtle about a kid getting crushed by a truck. Yet look at the range of emotion it must arouse in his family and friends. After all, that is what the great novelists try to do, fictionalize some human trait that each of us recognized before. But the soap operas do it with a sledgehammer. They don’t probe or dig around the subconscious. ‘Here’ they say. ‘What’s worst than this death, or better than this marriage? Each should evoke an entire spectrum of response in 15 minutes of airtime.’ I think they are pure genius.” I looked at him to see if he was kidding. He wasn’t. “So how does Welby fit into this?” “It’s the same sort of thing, it’s authentic. Here’s a mature inside view of real tragedies and problems of life, except that there is hope. The hope that medical science offers now is unbelievable, compared to even a score of years ago. You don’t like Welby, I take it.” “Oh I guess it’s all right. But I find it funny when Kiley hangs an x-ray upside down or they give a lethal dose of something and the patient sits up in bed smiling.” “Even real doctors make mistakes on occasion, Harry. But the fact is that Welby promotes something that may soon disappear in American medicine, if third parties become paramount, if doctors become employees instead of independent practitioners. That’s the doctor-patient relationship. Foremost in the mind of Welby is his responsibility to the patient. He doesn’t let himself be sidetracked by ancillary considerations. While the patient is in his care he assumes guardianship, and brooks no interference with that responsibility. I find it touching. A great act of faith. A good example to patients and doctors alike. I’ve seen him fight off administrators, nurses, family, and even other doctors to accomplish what he believes is for the good of his patient. I learn a lot, even medical things from the program.” Meanwhile we had arrived at the Medical Society. I paid the driver while Lapius ambled in. He returned in a huff. “There are no more refreshments, Harry. Next time don’t dawdle so. We’ll leave the moment Welby is over.” 5Euthanasia and Dr. Osler Daily Observer May 3, 1973
I scurried in from the cold, tamped the snow from my boots and hung my coat on the rack over the plastic mat to let the melting ice drain off. Since Lapius had become addicted to Marcus Welby I had decided to go to the lecture alone. He snapped off the TV as I entered. “Good meeting, Harry?” “Interesting. Fletcher spoke about the responsibility of the doctor to the dying patient.” “Euthanasia?” “Who said anything about euthanasia?” “Well originally euthanasia referred to the proper way of comforting the dying patient. That’s what it means literally, the good death. Now, of course it is synonymous with mercy killing.” “Fletcher didn’t touch on that, but rather on the new science of caring for the dying, of developing a dialog with them and helping to allay their fears.” “Interesting. It has been my experience that the healthy have more fear of dying than those face to face with death. Patients seem to undergo a gradual detachment that enables them to die peacefully.” “Fletcher read a letter from a young woman who was dying. She wanted to be comforted, and told the doctors that to them death might be old hat, but to her dying was a new experience.” “Well, I think it’s going to be hard to teach. Not all of us are equipped to shepherd the flock for the spiritual experience of dying.” “How was Welby tonight? Another short course in medicine you so sorely need, no doubt.” “Don’t be a snob, Harry. Welby was great, as usual. I’ve been trying to figure out what attracts me to him. After all there have been other programs dealing with the dramatics of life and death in medical practice, both in and out of hospitals. But there is something particularly sensitive about Welby, and therein, for me at least, lies his appeal. It’s that the program doesn’t really focus on whether the patient will live or die, but that, regardless of the outcome, the patient is in competent hands of someone who cares. The patient is not alone. Welby is concerned about his patient as a person. This is what comes through, Kiley tries to be but isn’t yet mature enough to project it. Welby has already faced death himself, he had a heart attack and is not well. I think this is vital to the characterization. And luckily they were able to get Robert Young to play the part. He was an alcoholic for many years, and his struggles with that disease probably enabled him to develop the mellow warmth he projects on the screen.” “Fletcher said that doctors are getting a bad press from their seriously ill patients.” “I think that’s an exaggeration. Some doctors to be sure may be abrupt with the dying, and if they are it is because they themselves are afraid. But in my experience most doctors eventually come to terms with death, regard it almost as a friend after having seen it rescue people from useless suffering. We used to call pneumonia the old man’s friend. I find that most doctors are kind and considerate to the dying. But never mind that. Here’s a mother’s account of the great William Osler’s approach to her dying daughter.” Lapius plucked Harvey Cushing’s biography of Osler from his shelves opened it to a marked page, and proceeded to read. “He visited our little Janet twice every day from the middle of October until her death, a month later, and these visits she looked forward to with pathetic eagerness and joy. Instantly the sick room was turned into a fairyland, and in fairy language he would talk about the flowers, the birds, and the dolls-. In the course of this he would find out all he wanted to about the little patient.” “The most exquisite moment came on old raw November morning, when the end was near, and he brought out from his pocket a beautiful red rose, carefully wrapped in paper, and told how he had watched this last rose of summer growing in his garden and how the rose had called out to him as he passed by, that she wished to go along with him to see his ‘little lassie’. That evening we all had a fairy tea party at a tiny table by the bed, Sir William talking to the rose, his little lassie and her mother in a most exquisite way – and the little girl understood that neither fairies nor people could always have the color of a red rose in their cheeks, or stay as long as they wanted in one place, but that they nevertheless would be happy in another home and must not let people they left behind, particularly their parents, feel badly about it; and the little girl understood and was not unhappy.” “Great,” I said, “but who has time for fairy tea parties?” “Harry,” Lapius said soberly, but not without a twinkle in his eye, “If I should find myself in your care when I am dying, promise me you’ll call in an older man.”
Alcohol and the Mind Daily Observer May 10, 1973
After dinner, S.Q. Lapius bolted his wine, corked the bottle and rushed it off to the cooler. “We’ll finish it later,” he mumbled. When he returned he said, “Help me for a moment, Harry, we have to clear the sideboard. You take the decanters, I’ll remove the liqueurs.” “What’s going on. Did they pass the Volstead Act again? Are you being raided? Is the WCTU paying a social call?” “None of those things. Much worse, Johnny Sipley is coming. He called earlier. Wants to talk to me. Hurry, he’ll be here any minute.” “What’s with Johnny Sipley that we have to rearrange the whole house. Is he an interior decorator?” “As a matter of fact, he is, but he’s also an alcoholic. Let’s get these bottles out of the way. He’s been dry for quite a while. I want neither to tempt nor offend him. Here take this to the kitchen.” He handed me a tray filled with scotches, ryes and what not. Lapius was quite partisan to spirits fermenti, so clearing away the reminders of his imbibational hobbies was time consuming. Just as the bell chimed he removed a Flemish masterwork portraying a tavern scene, replacing it with a mirror he hurriedly scooped from his bedroom. Sipley was a tall, blond, pink cheeked, urbane and smiling. I helped him off with his coat and could detect no hint of alcohol on his breath, nor was it hidden by breath sweetener. There were the usual expansive amenities with Lapius, who was an effusive host, so that by the time he finished the hellos Sipley was already apologizing for not having come more frequently. Lapius turned to me, “Harry, Mr. Sipley wanted to talk privately, will you excuse us?” “No, Simon, that won’t be necessary. There’s nothing that Harry can’t hear. As a matter of fact, it’s a medical problem. Two doctors are better than one, eh?” That was supposed to be a joke. Before he began, Sipley roved about, admiring the décor, then said, “Simon, whatever happened to that lovely Flemish Tavern Scene. The mirror adds nothing to the room.” “The museum wanted to borrow it for their retrospective exhibit,” Lapius said blandly. “What’s on your mind Johnny?” “Well, to tell you the truth – “ Lapius interrupted him. “Please don’t introduce that insipid phrase as preamble to any discussion with me. What’s your alternative to telling me the truth. You surely didn’t think that I expected you to lie to me, did you?” Lapius was clearly picayune. He had, after all, been deprived of his after-dinner Benedictine, and that always made him grumpy. “Never mind, excuse me, Johnny, go ahead.” Sipley continued, “Well, to be honest, Simon,” Lapius, resigned, refrained from interrupting again. “I have a medical problem you might be able to help me with.” “Have you consulted your physician?” “Of course I have, several. And that’s the problem. I’ve had abdominal pains for about two months now. They bother the devil out of me and interfere with my concentration. I have to rest during the day.” “What did your doctor say?” Lapius asked. “That’s just it. The first one, I won’t mention names, is my regular doctor, and after a few questions wanted me to get some x-rays.” “Not a bad suggestion. Did you follow it?” “No I didn’t. He insisted that I go to Krauser. That’s what set me off.” “Krauser is an excellent radiologist.” “Maybe, but why does he always send me to Krauser. Is he getting a kickback. I asked him to send me to someone else.” “What did he say?” “He said sure, pick one. How the hell can I pick one? I’m not a doctor. I don’t know the guys. He wouldn’t give me another name. So I went to another doctor, told him my story, and he wanted me to go through a complete physical exam. What the hell do I need that for. I just had one 3 months ago.” “With that doctor?” “No, with my first doctor.” “Well the second doctor sounded reasonable.” “I don’t think so. I assured him my physical and tests were o.k. He was just out to bill me for $100 bucks.” “What do you want me to do for you, Sipley?” “I want you to send me to a doctor who will help me. You know all the men in town.” “Johnnie, I’ll try to help you. But first, Harry and I were just about to have a drink when you arrived, what will you have.” “Bourbon straight,” Johnny said, without blinking. Afterwards I checked the bottle. Johnny Sipley used about a third of it and had walked a bee-line when I showed him to the door. It didn’t touch him. “I don’t understand you, Simon.” I said when I returned. “First we spend half hour hiding the drinks, then you offer him one. That’s no favor to an alcoholic, you know.” “He was off the wagon.” “How do you know?” “Because he had suffered a change of personality. Normally he’s reasonable. He never gets drunk, when he’s drinking, he becomes unreasonable, illogical, and slightly paranoid. Everyone’s out to get him. Usually he’s a tractable patient. Some alcoholics are more rational when drunk than sober. But the main thing, in my experience is the change in personality.” “Now of course the alcoholic is distinguished from other drinkers by the fact that he’s addicted to it. But it's the change in personality that strikes me. After all, you are Harry drunk, and you are Harry sober. But Johnny Sipley is one person when drunk and another when sober. One problem of the alcoholic, in my view, is the inability to integrate two personalities. To develop psychological stability they have to evolve a third personality that is a compromise of the extremes. But if once they touch liquor again, that will dissolve in favor of the original personalities.” “So believing all that, why did you offer him a drink?” “To be sociable. He would have gotten it somewhere. Incidentally, now you know why he started each sentence with ‘to tell the truth-.‘” Emancipation of Women Daily Observer May 17, 1973 We were at The Pawn Shop, a local chess club, where S.Q. Lapius, M.D. was playing Elizabeth Fischer, M.D. in the first round of the club championships. The match attracted no attention. When Elizabeth pushed a pawn to the seventh rank, Lapius surveyed the shambles of his defenses, the precarious position of his king, looked at his watch and said, “It’s late dear girl. I think I’ll retire.” “You mean you resign?” asked Elizabeth. “Well, yes, after a fashion.” Lapius was never a gracious loser at chess, but to lose to a woman was particularly vexing. “Well, Simon,” she said after they had shaken hands across the board, “it proves the old adage, the female of the species is deadlier than the male.” “Don’t be tedious, Elizabeth. Must you keep dredging up those silly sophisms. Why must the obvious fact that you are a female be dragged into a chess match?” “But Simon dear,” she asked him, “wasn’t it during dinner that you said that women weren’t as competitive as men?” Lapius rose to the bait. His visage reddened slowly to the intensity of a scarlet sunset. “Nonsense, Elizabeth. I said no such thing. I shan’t be inveigled into these specious arguments,” he said, immediately becoming inveigled. “After all, I have always held you in the highest esteem, as a colleague, a scholar, and gentleman.” “Gentleman and scholar indeed!” said Elizabeth reddening as if she had just received a transfusion from Lapius. “You a bachelor, what would you know about women?” “I must admit that most of what I have learned from you about women during our long relationship has not but confirmed my prejudice against marriage.” “Simon,” she all but shrieked, “you are becoming insufferable. You epitomize the lordly male to whom all womanhood must be forever obeisant. I too have an admission to make. Knowing you has made me a feminist. Why shouldn’t women have equal opportunity for jobs, equal pay scales, child care centers -.” Lapius silenced her with am imperious sweep of his arm. “Silence woman,” he said. Believe it or not, the innate sense of female subservience spun from the cottony threads of genetic memory took control, and Elizabeth stopped talking, her mouth agape. “None of these are serious issues. You became a physician, a mother, a wife, although perhaps not in that order. You seized the opportunity. The market place will decide jobs and pay scales and things of the sort. Day Care Centers are becoming a social necessity, although I question the early deprivation of maternal influence. But nary a word do I hear about significant problems. “Why is it that women who clamor for freedom subordinate themselves to birth control devices? By the bushel they submit to tubal ligation and even serious extirpations in order to achieve inconceivability.” He didn’t even stop for breath. “If he were to judge by the gross sales of medications, a future historian might guess that the one disease feared most by our civilization is pregnancy. Look at the risks you women incur; the ‘pill’ which increases the risk of thrombo-embolic phenomena about ten fold, the emplacement of intrauterine devices, some of which cause for perforation, others of which induce infection; the wild clamor for abortion, to alter what might have been prevented in the first place by forbearance, timing or the fastidious use of harmless devices. You think you’ve gained freedom from the home by freely inflicting these dangers on yourself. You think you’ve gained sexual freedom, which will enable you to join the world of men. But all you’ve done is to enslave yourself to harmful remedies. Suddenly the liberated women is willing to mutilate herself so she can freely service the male of her choice. That’s not liberation, darling, that’s captivity. Congratulations. You played a fine game.” With that he turned and stalked out, with me, his retinue, behind him. “Gosh, Simon,” I said as we walked home in the bitter chill, “Don’t you think you were a little rough with her?” “Ridiculous. I was just treating her as an equal.” Then he stopped in his tracks, and muttered to himself, “Elizabeth Fischer, Elizabeth Fischer. Maybe that explains it.” “Explains what?” “Why I lost to her. I think he’s her cousin.”
Psychiatry Daily Observer May 24, 1973
Religion, Insanity, Psychiatry
S.Q. Lapius had just explained the four psychiatric models currently in use, the Medical, Psychological, Behavioral, and Social, none of which dissolved the clots of confusion that obstructed my mind. The medicinals that James the bartender dispensed, although not diminishing the confusion, somehow made it seem less important. “There, Harry, you feel better,” Lapius noted. “Alcohol is no solution,” I replied. “But it’s relaxing,” soothed Lapius, already quite relaxed himself. “I guess we’re the alcohol generation.” “Spiritus fermenti, Harry, is a time honored remedy.” “Fifty years from now some one will be saying that about marijuana and heroin, I guess,” I said morosely. “Perhaps. Particularly if we learn to govern their use.” “Certainly the prevalence of these drugs, alcohol included, is testimony to the failure of psychiatry to spread its benefits quickly and economically to the majority of the public. Man’s mind is like an iceberg, about 10 per cent of which is rational, the other 90 per cent buried deep in the unconscious. There is no unwritten law that says the mind of man has to be rational, that it is born rational.” “How do you define rational?” “I think of it in terms of the system in which a person lives. In western civilization it means some logical process of thought, that came down to us from the Greeks, got lost somehow in the dark ages, and was resurrected by the arduous ‘thinking’ labors of Bacon, Descartes, Copernicus, Newton, Einstein. Our entire technology has been built on the logical sequences that we have extracted laboriously from nature. Science has an appealing advantage in that truths can be proved, and problems can be solved. But there are civilizations in which it is rational to be entirely religious, and in these societies there is very little technology. In fact there is poverty, but it is accepted as part of the nature of things. We in our society would consider that irrational, and they would of course return the compliment.” “What has this to do with psychiatry, which is what I thought was the subject.” “Simple, Harry, the ‘irrationalities’ of those religious societies are being introduced into our society. Of course you must remember that all religion is fundamentally not rational, as it is a function of faith. Traditional religions are acceptable irrationalities, in that they function for the society in which they are predominant. In the western world the Judeo-Christian religion until recently has satisfied man’s yearning for knowledge of the metaphysical, so that the rest of his mind has been free to investigate, build, create on a logical basis. Ergo, our technology has developed. Some more easterly religions, however, are so encompassing, that there is no mental energy left over for creative thought. Ergo, no technology.” “It sounds simple, Simon.” “Harry, please don’t juxtapose my name with ‘simple’. Anyway, what I was trying to say is that psychiatry is an attempt to quantify the great unconscious. Successful religions simply harness it; they don’t try to define it. But here in the west, we try to adjust it to our traditions of logic and measurement. The new breed will dispense with terms like schizophrenia. They will say that a New York schizophrenic transplanted to India will not be a schizophrenic. That everyone has several different personalities. The concept seems to have originated in the literature of Herman Hesse, a book called Steppenwolfe, sort of a bible to the youth. He felt that the people had a right to express their different personalities without being incarcerated in asylums. Then comes J.D. Laing, who claims that schizophrenia is merely a sane response to an insane world.” “Yeah I’ve heard that stuff. The earth is the insane asylum of the universe.” “Ha ha ha, that’s a good one,” Jimmy the bartender said. “Please, James,” Lapius admonished. “This is a serious conversation.” Then he turned to me. “Precisely, Harry. Anyway, what has happened is that the ungovernable unconscious in western civilization is no longer bound irrevocably to the Judeo-Christian tenets and is floating free. There is mass floating anxiety, the depression of the drug-users, and the unacceptable irrational pseudo-religions that have sprung up. Psychiatry used to have a base-line from which to work. But now it is splintered in direct proportion to the splintering of the religious base of the nation.” “Do you believe the nation has lost its spiritual base?” “No, not lost. Splintered. Instead of one belief there are many. Hindu mysticism is becoming popular. Thousands of people are reciting mantras before bhagwans, swamis and self-proclaimed maharishes and gurus. There are witchcraft clubs in California. Thousands seek peace and unity in the lotus position and others proclaim salvation while standing on their heads. The entire society has lost its sense of unity.” “Are you saying that our society in America is schizophrenic?” “No.” Lapius said bluntly, “I am not saying that.” “Excuse me. It sounded like it. After all, if our society has lost its unity, it has become many different selves.” “Correct, Harry, but here is where I differ with the latter-day soothsayers, with their denial of the existence of schizophrenia. Certainly an individual can have many different selves, but if he is normal, he is aware of the different faces he exposes to different conditions, and deep down, recognizes them as extensions of a unitary self. The same with our nation. To date we can indulge the splintering because the nation still has a sense of itself as a unitary society. Only when that deep intrinsic sense of unity is destroyed will the nation become schizophrenic.” “Then what.” “It will falter. It will lose its cohesiveness. It will lose its identity.” “And psychiatry?” “Psychiatry can’t function in a void. It has to have a value system to relate to.” “Then psychiatry itself is becoming schizophrenic.” Lapius drew a deep breath, then said, “I’m afraid so, Harry, I’m afraid so.” “No hope, then.” I muttered pessimistically. “I didn’t say that. Of course there’s hope. Civilizations manage to become unified through some value system or other. A God they can all believe in.” The drunk next to us smashed his glass to the floor and shouted jubilantly, “Out with the old God, in with the New.” Lapius watched in astonishment. “But we may be in for a very difficult transition, Harry.”
Talk to the Rotary re the Unpopular Doctor Daily Observer May 31, 1973
A few weeks after the talk to the Rotary, Lapius, well recovered from the laryngitis that had rendered him hoarse de combat, was seated at his desk punching at the typewriter. “Writing imperishable prose?” I asked him. “Not exactly,” he said, adjusting the green eyeshade which he always wore when writing. “I am trying to answer stupid questions. Since I couldn’t respond from the floor at the Rotary because I had lost my voice, you remember, the night Tunney presented my lecture, I suggested that questions be mailed to me and I would try to answer them in writing. But it is a thankless chore.” “Why so?” “Well, if you err from the podium, you can always deny you said it. But how can you deny you said something that you have written and signed. It’s like a contract.” “What are the questions?” “Strangely, many people want to know why doctors are so unpopular. I thought that was covered in the talk, but Tunney swallowed my words and must have swallowed those in particular.” “But it’s an interesting question. Why are doctors unpopular?” “That’s just the point. They aren’t. Doctors’ offices are always crowded and appointments must be scheduled well in advance. That’s not unpopularity. Quite the contrary. And in fact the medical profession is under attack for not providing enough doctors. If people want more of them around, they must like them.” “Well, still I get the feeling at times that we are under attack. The Physicians Forum for instance, rails against the profession as it stands and says that the elite role of the doctor must be abandoned, whatever that means. The government moves the economy into Phase Three except for doctors who stay in Phase Two. Doctors have to buy commodities at Phase Three prices with Phase Two money. It strikes me as discriminatory.” “Of course it’s discriminatory, Harry. The government is trying to keep the cost of medical care down, and unfortunately the doctors are caught in the crackdown. But it’s not because they don’t like doctors, it’s because they don’t like doctors to earn too much.” “What’s too much?” “Well, no one in government has defined that yet. For instance, an executive at General Motors who earns $100,000 yearly isn’t earning too much. And when he retires on a pension of $50,000 he isn’t earning too much either, apparently, despite the fact that his contribution to society is nil. Fortunately he hasn’t in his lifetime become a necessity to society, so they don’t pay too much attention to his income. But doctors are apparently vital to the health of the country, or so the government would have you believe, so they regulate them somewhat, as they would any utility.” “You make it sound reasonable Simon. But doctor’s fees probably don’t represent more than 20 percent of the national yearly medical bill. Look how often a patient pays $10 for a visit at the office, and $15 for the prescriptions. For two weeks of hospitalization a patient pays about $2000, even more when surgery is involved, where the medical bill probably doesn’t exceed $200.” “Of course the big jump in medical costs accrues from the immense increase in hospital billing. That’s because for years the major subsidy to the nation’s health came from underpaid hospital employees. But they unionized and are paid union scale, which must have doubled hospital costs.” “So why don’t people resent hospitals?” “How can you resent a hospital? What do you resent? The building? The beds? The telephone operators? The administrator? The board of directors? It’s an anonymous entity. It’s a physical plant run by ghosts. It’s passive. But a doctor is flesh and blood who is doing something actively to your body. He can be confronted. Did you ever try to confront a hospital? How do you confront a hospital? Even the doctor working in the hospital doesn’t know how to confront it. He has to go to committees. And the committees have to approach other committees. Sometimes the same people sit on both committees. You know what a committee is, Harry. A camel is a horse that was put together by a committee. But the fact is Harry, that with all the griping, no one resents either doctors or hospitals. They resent the cost of the system. Illness is a cruel accident that penalizes people financially when they are most vulnerable physically. That’s the dilemma, Harry, and the solution will not please everybody.” Lapius went back to the typewriter. “How are you going to answer the question, Simon?” I asked as he adjusted the green eye shade. “I just did. Now if I can only remember what I said --.”
Bill of WrongsDaily Observer June 11, 1973
We were having a quiet evening. S.Q. Lapius had graciously permitted me the use of his recliner while he sat busily at his desk scribbling on his yellow foolscap. I struggled to wade through the quarterly issue of the Archives, fighting sleep every inch of the way. Finally, just to keep myself awake I called across, “What are you writing, Simon? Another paper?” “No, my boy,” he answered without looking up. “Some amendments to the Bill of Rights.” “The Bill of Rights. You’re 200 years too late.” “Not that Bill of Rights. The new one. The Patients’ Bill of Rights issued by the American Hospital Association.” “Ho hum,” I said, closing my eyes again. “Don’t be derisive, Harry. It’s very important. The American Hospital Association has written a presumptuous document that would be ludicrous if it didn’t deal with so serious a subject. Listen to some of this. They have twelve items. I’ll read some to you, if you’ll excuse my editorial comments.” “Go on,” I said, eyes still closed trying to concentrate on the Bolero drifting in over the hi-fi. “Harry, move over to the hardback chair while I read. Then perhaps you will stay awake.” “1. ‘The patient has the right to consideration and respectful care’.” “Sounds okay so far,” I said, while walking over to the hard-backed chair. “No argument. It goes without saying. It seems the one principle that is implicit in patient care. Why does the AHA have to discover it at this late date? Then they go on to the patient’s right to informed consent from his doctor. Again no argument, but certainly not a matter for hospital concern. But they say ‘The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and-or treatment.’ That is very broad, what? Does it include all medications? Will the doctor and his patient have to discuss the pros and cons before an enema is ordered?” Lapius was warming to the task. “Here, “4,” ‘The patient has the right to refuse treatment to the extent permitted by law – What law forbids a patient to refuse any treatment?” I thought about that for a moment. “I think they refer to guardianship. A patient under guardianship probably couldn’t refuse treatment if the guardian approved.” “Well, that’s a sticky wicket,” Lapius said. I had never known him to retreat from an issue so readily, but he was anxious to get on. “Forget that. Let’s go on. The following two emphasize the patient’s right to privileged communications ‘The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential.’” “Agreed.” “Of course agreed. But then that would preclude review of the patient’s chart by utilization review committees without the express approval of the patient. And since those committees are only trying to determine whether the third parties, the Blues, or government should continue paying the patients medical bills, why should the patient agree to that? Yet hospitals all have these committees, and I doubt that the patient is ever consulted about whether his case should be reviewed by any other than his doctor.” “That’s a point,” I said. Lapius pursued the matter relentlessly. “Look at “7,” ‘When medically permissible a patient may be transferred to another facility only after he has received the complete information and explanation concerning the needs for and alternatives to such a transfer.’” “That’s a step in the right direction, isn’t it?” “How? It doesn’t protect the patient’s rights. They will move him whether he or his doctor wants him moved. They may explain why, but they’ll move him nevertheless. Where does it say that the patient has any rights of appeal against this decision. It states that after informed consent the hospital can do what it wants. It’s the hospital’s rights that are being protected, not the patient’s. Let’s look at No. 9, ‘The patient has the right to be advised if the hospital proposes to engage in or perform human experimentation affecting his care or treatment.” “That’s good, I don’t see anything wrong with that.” “Harry,” he seemed exasperated, “I think I know what they mean. They want to say that the hospital will not allow members of its staff to perform experiments, etc. But they didn’t say that. They said’—if the hospital proposes to perform.’ Hospitals don’t do experiments. “A hospital is a building, a haven for the ill, a hospice. It is made of brick and mortar. It doesn’t treat, or do experiments or do any of the things that people do. The AHA can no longer distinguish the inanimate. Of course that’s their problem. They think in impersonal terms. Now look at “10.” ‘The patient has the right to expect reasonable continuity of care’? This isn’t a bill of Rights, it’s a bill of Wrongs.” “You take them too seriously, Simon.” I said, hoping to get back to the recliner. But that wasn’t the right thing to say. “Of course I take them seriously. This is a manifesto by the American Hospital Association, a hodgepodge of loose thoughts, inexactly expressed, intruding into business other than their own. It should really be a statement of intent. For instance, here’s how I would put it. ‘The Board of Trustees of the American Hospital Association that hospitalized patients have the following rights: 1. To know that all members of the medical and nursing staff are duly accredited. 2. The right to privileged communication with their doctor. To know that their medical records will not be shown to any third party or representative thereof without the consent of the patient. 3. The right to proper continuity of care; there will be adequate staff available day or night, weekends or holidays to properly carry out the doctor’s orders. 4. The hospital administration will not evict a patient or transfer him to another facility without the consent of the patient in accordance with that of his doctor. 5. The ecology of the hospital will be maintained at all times to the highest standards of cleanliness and comfort. “Well,” Lapius said, preening a little, “How’s that for starters, Harry?” “Great. Can I go back to the recliner now?”
Comment 2006 The patients’ Bill of Rights emerged 25 years prior to HIPAA, Health Insurance Portability and Accountability Act of 1996 that formalized the concept of privacy. But the law and statute are harsh, and sweeping penalties can even implicate physicians and nurses who happen to leave charts on their desks that might be seen by some one of mal intent. This imposes an additional responsibility on health care providers, and imposes restrictions real or implicit on case management.
PSRO, PCA, UPRO? Why Not Some TLC? Daily Observer June 28, 1973 Gautier grinned. If there is such a thing as a malevolent grin, Gautier owned one. His waxed moustache pointed down while the corners of his mouth creased an upward arc. “You medicos will finally be put up against the wall, now that HR 1 has been enacted to monitor the finances of the medicare and medicaid laws. Are you going to join the PSRO, Lapius?” “You throw initials around like any pretentious bureaucrat, Gautier. Why PSRO? Why not a PCA, or a UPRO, or maybe OSCHUR.” “What are they? I’ve never heard of them,” Gautier said, his moustache wiggling a bit to denote bewilderment. “Well, then, Gautier, let’s not toss initials around so pedantically. PSRO, of course stands for the Professional Standards Review Organization. The other acronyms stand for similar organizations. Gautier pursued his line of thought. “These all flow from the Bennett Amendment to the Social Security Act which says, in effect, that a physician has to justify continuing a mode of treatment that extends beyond standards established for the illness according to the patient’s age and diagnosis.” “Frankly, I don’t think it concerns me one bit,” Lapius pushed his chair from the table, leaned back, and lit one of the large black Havana cigars he imported from Nicaragua. “Aha, typical doctor’s comment. Ready to flout the law,” Gautier said gleefully. “Don’t come crying to me, Lapius, when the government tries to put you in jail.” Lapius snorted and blew a cloud of smoke that enshrouded Gautier and started him sneezing. “I’m not flouting the law. I’m not interested in Peer Reviews, not in hospital bed utilization. My job is to take care of my patients. When they are hospitalized, I will keep them there until I think that medically they are ready to go home. If the government chooses to cease payments, that’s between it and the patient. I inform all patients who have been hospitalized for a protracted period that insurance might not cover extended stay and they may have to meet the bill. They are free to sign out of the hospital if they choose to. But then they leave on their own responsibility. I certainly won’t take the medical responsibility for aborting their hospital stay if I think it’s risky.” “But, Lapius,” Gautier became serious. He wasn’t needling now. “You have a responsibility to the community. You can’t usurp beds unnecessarily—” The word unnecessarily was a mistake. It galvanized Lapius into attempting to stand up quickly, which involved a frenzy of activity. First his chair was too tight, then he was still too close to the table. He shoved mightily and the table slid away. When he struggled to his feet the chair spun off his backside to land upside down. Lapius ignored it and turned to Gautier “UNNECESSARILY?” he thundered. “Is it you, Gautier, who will determine how long my patient stays in the hospital? He’s not your PATIENT, or the GOVERNMENT’S PATIENT. As long as I’m the doctor he’s MY patient, and I’ll brook no interference. He can go home anytime he wants to; all he has to do is sign himself out. I’ll inform him of the risks. Don’t talk to me about community responsibility taking precedent over the responsibility of a doctor to his patient. NOTHING takes precedent over a doctor’s responsibility to his patient.” “You’re too excited, Lapius,” Gautier cautioned. “But let me understand. Are you saying that doctors shouldn’t be involved in the utilization review.” “Precisely. This isn’t oriented towards patient care. No one is checking on the care given the patient by the doctors, the hospital, the nurses. It’s strictly a watchdog operation to govern finances. Who will patients sue if doctors become so skittish by having someone look over their shoulders that they discharge patients prematurely? The Government? The PSRO? Not on your life. They’ll sue the doctor. And they’ll be right.” “But Lapius, you know that hospital beds are over utilized.” “Listen, Gautier, you are a lawyer. What background in medicine, other than what you’ve learned in your close association with ambulances, gives you the expertise to judge complex medical problems?” “But other doctors can judge.” “No one can judge. No one unless they know the patient, his disease, his family, the accommodations at home, the temperament of the people he’ll be going home to, the distance of the home from the hospital, the availability of outpatient nursing service… . What gall to believe that an outsider can come in, whatever his qualifications, and intrude on a doctor-patient relationship in such a manner, merely to decide the merits of the case in relation to the costs the government is willing to expend! No, Gautier, doctors should not be concerned with anything but that patient’s illness. Anything else is a community problem. Maybe the community needs more hospitals, more extended care units. Maybe hospital costs are too high. But none of these considerations should be brought to bear on an individual illness.” Lapius paused for breath, and then said sweetly, “But we are old friends, Gautier. We shouldn’t argue. Let’s change the subject. What’s the current status of no-fault insurance?” Gautier turned pale. The tips of his moustache trembled and twitched. He slammed his hand on the table. “What right has a government to decide that there is no fault in an auto accident, or that a client isn’t entitled to proper legal representation?” “I’m not sure I agree with you, Felix.” Gautier stood up, more gracefully than had Lapius several moments before, walked up to the still-standing S.Q. Lapius and waggled a finger under his nose. “You’re a doctor, not a lawyer. What do you know about legal matters? Stick to your own profession.” “I intend to,” said Lapius, “I intend to.”
Selecting a Shrink Poses Problem Daily Observer July 6, 1973
“You’re distraught, Harry,” were the words S.Q. Lapius greeted me with as he entered my office. “Why do you say that, Simon? Just because I threw this sheaf of papers on my desk in disgust and they scattered all over the floor?” “That was a clue, I must admit,” Lapius said impassively. “What seems to be the trouble?” “How the deuce does a doctor choose a psychiatrist?” “Come Harry, things can’t be that bad. Take a warm bath. That will sooth you.” “Not for me, Simon,” I said with no little exasperation, “for one of my patients.” “That should be simple, Harry. Look up psychiatrists in the medical directory, under ‘P’.” “It’s not that simple, Simon. An internist is an internist, a surgeon is a surgeon, but a psychiatrist isn’t always the psychiatrist for a given patient. They differ. I get varying results, and I can’t figure it out.” “Too bad, Harry,” he lamented, squinting owl-like through his bifocals. He placed a cigar into his mouth and said, “You haven’t been keeping up with the literature, I see.” “How so?” “The problem is explained in the New England Journal of Medicine the issue of February 15, 1973, an article by one Aaron Lazare. The trouble is that there are different schools of psychiatry. He lists four particular models by which psychotherapy might be effected: the Medical model; the Psychological model; the Behavioral model and the Social model.” “I must admit I missed that one, since I’m only up to the 1967 volume of the Journal, but I’ll get to it, I promise.” “Skip ahead, Harry, it will be worth your while.” “Will it help me pick the right psychiatrist for the right ‘patient’?” “Perhaps. At the very least, it will show you what you are up against. For instance, the Medical model. Here the physician makes the diagnosis of depression. Once the diagnosis is made he seeks a medical form of treatment, either drugs or electric shock therapy. “But if your psychiatrist is oriented to the psychological model he is oriented to treating personality that has been distorted by past experiences and he attempts treatment for emotional traumas the patient suffered as a child. The doctor forms an alliance with the patient so that together they might examine the past, and try to straighten out the distortions once the patient becomes aware of them. “But then there is the behavioral model, in which the doctor attempts to alter aberrant behavior patterns and doesn’t worry about the prior traumas that caused them. These doctors use terms like desensitization, reciprocal inhibition, and conditioned avoidance.” “What do they mean?” “Beats me. But the important thing is that the psychiatrist in this model identifies the symptoms of lack of appetite, feelings of helplessness and so forth. He determines that the symptoms started shortly after the death of her husband who, throughout the marriage had been a continuing source of reinforcement. “His death is considered ‘a sudden withholding of positive reinforcement of adaptive behavior’. The treatment consists of reinforcing behavior patterns that are inconsistent with depression and attempting to extinguish depressive behaviors. Here the psychiatrist has to teach the family to reinforce positive behavior patterns.” I started to say something unpleasant, but Lapius raised his hand pontifically to silence me. "Not a word until I’ve finished, please. We have yet to cover the social model.” I sank back into my swivel chair, defeated. Lapius continued. “In the social model the psychiatrist concentrates on how the individual functions in the social system ‘—the type and his ‘connectedness’ to the groups which make up his life space.’ Here the therapy consists of reorganizing the social system in which the patient exists. Have the patient move out of her daughters house, or go to another town, or change jobs, things of the like.” “Let’s get back to the original question. How do I fit my patient to the proper psychiatrist?” “I guess the only proper way, Harry, is for you to acquaint yourself with the ideologies of the psychiatrists to whom you would refer patients, and then monitor the therapy. If the patient after a reasonable period of time is not improving, suggest, perhaps another mode of treatment. To do this you must discuss the case with the psychiatrist in advance.” “I’m confused.” “Of course, my boy. Let me help you. I will treat you with the four modalities. Knowing something of your background, and having just learned of the problem that besets you, we can dispense with the psychological approach. For the behavioral, I will urge you not to scatter your papers or get into a huff, it is most uneconomical. “The social therapy is simple. We must change your environment. We do this by repairing to the nearest watering hole. There, James will take over from me, and supply the medical treatment.” “Who is James?” “The bartender.”
Hospital Bed Shortage Daily Observer August 2, 1973
S.Q. Lapius was impatient, “Come on Harry. I need the phone. You have been on it for an hour.” I waved him to silence, and finally hung up. “Sorry, Simon, but I’m trying to find a hospital bed for a patient of mine who is quite sick.” “No beds again?” “That’s right. They have them in the halls. One place said they even have one bed in an elevator.” “Surely an exaggeration,” said Lapius smugly. “Surely not. How come you don’t have this trouble?” “My patients, by and large, own the hospitals.” “Well, for us poor plebes the situation is different. Honestly Simon I don’t know what’s going to happen. It’s getting worse all the time. Now that the government wants to terminate the Hill-Burton program which provided matching funds for the construction of hospitals, beds will become less available than ever.” “It’s hard to achieve a proper balance, Harry. If too many beds are available then hospitals with poor occupancy rates go broke. One reason for the high occupancy is that not all insurance plans cover outpatient work-ups, and physicians and patients alike find it convenient to hospitalize for work that could just as easily be done in the physician’s office. “That’s not as prevalent as it used to be. I’m inclined to think that the prime cause of hospital bed utilization now is for terminal cases, and for the elderly and infirm who simply can’t be expected to run back and forth to doctor’s offices daily for a work-up. “For example, a patient needs a barium enema, he’s ninety years old, crippled, living with an eighty-five year old wife. How can you give him a laxative the night before, and expect his wife to give him enemas the following morning so he can then call a taxi or a rescue squad ambulance to cart him to and from the hospital for the procedure? That patient should really be hospitalized for a day or two. “I know what you are going to say, Harry. You hospitalize the patient, but no bed is available until Friday. This patient doesn’t have the X-ray work scheduled till Monday. While he is in the hospital why not take advantage of the situation and do a complete work-up. By the time the patient leaves a week has passed.” “Absolutely, Simon, providing you haven’t discovered some other condition in the meantime, or asked for consultation. By the time a consultation request is written and the consultant actually sees the patient and his report is on the chart, at least three more days have passed.” “You know, Harry, considering those days, plus the 75 or so days a year that are holidays or weekends, at an average rate (and I know this is low) of $100 per day, considering a hospital of a hundred beds, the community, including the insurance carriers lose about one million dollars a year. Multiply this by the number of hospital beds in the country and I bet the bill runs to a billion dollars or more.” “You’re right. You know what they ought to have, Simon? They ought to have ‘work-up’ hospitals, where a patient can go to a hotel type of domicile, be transported to the hospital for tests, and be taken back again.” “Would this new facility have nurses?” “Yes.” “Would it be a nursing home or hospital, or what?” “I haven’t figured that out yet.” “You better if you expect the Blues or other insurance carriers to pay for the stay. And if they do pay for it the costs would just as high as in hospitals because standards would have to be met---.” “How about a private place, $30 dollars a day, meals, and nurse on premises as well as transportation? The hell with the Blues.” “No community would go for it. People no longer expect to pay for any part of their illness or incapacity.” “Then of course there’s the other side of the coin.” “What’s that, Harry?” “There ought to be more extended care units, you know, sophisticated nursing homes, that convalescing patients can go to.” “They exist.” “I know, but somehow they haven’t got sufficient round-the-clock services to make a doctor feel confident about sending sick patients there. So we keep them in the hospital longer than we might if these facilities were available.” “What I think you are saying, Harry, is that not every hospital has to have an X-ray department, an emergency room, or a suite of operating rooms.” I mulled that over for a while and agreed. “Yes, that’s what I’m saying.” “Well, then for goodness sakes, why don’t you say it? You could have said it half an hour ago.” “Sure, just like hospitals, everything takes a little longer
Organ Transplant
When changing liver, lung or heart or grafting many another part It might be said to those who quiz ‘The donor was --- ‘The recipient is ---,’ But moving into new terrain They’ll soon transplant the human brain. Will it be said when this occurs, ‘The donor is --- ‘The recipient was?.’”
Even in Treatment, You Just Can’t Win Daily Observer August 16, 1973
S.Q. Lapius was wearing his smoking jacket instead of his old bathrobe. “Why so formal,” I asked. “That orthopedic fellow, what’s his name, Dr. Pes Planus is supposed to come over. I told him I’d call as soon as I had finished editing this article. Give him a ring, will you Harry?” “What’s his number?” “It’s in the phone book,” Lapius said graciously, while he stretched out on his recliner and lit a long black cigar. I found the number and dialed Tibia 7-0234. Planus answered.
“The great one is ready, Pes. You can come over
any time now.” “A drink?” “Yes thanks, if you’ll add some cyanide.” “Mix Pes a drink, Harry.” “Okay Pes,” I said to the morose man, “Should I add liquor or do you want it straight?” Pes ignored me and turned to Lapius. “Simon, you know a lawyer named Gautier, don’t you? Felix Gautier.” Lapius was instantly cautious. “A mere acquaintance, my boy, why?” “Do you know him well enough to act as an intermediary?” “Perhaps. What’s the trouble.” Pes looked troubled. He was momentarily tongue-tied. “Here Pes, here’s your drink. Straight cyanide.” “Thanks,” he said and took a long gulp, like Socrates downing the hemlock. When nothing happened, he recounted the tale of the molested orthopedic surgeon. “Fellow came to me with severe back pain. I made a presumptive diagnosis of slipped disk and did a myelogram. Had no trouble putting the dye into subarachnoid space. I put the needle in between Lumbar vertebrae 3 and 4. But because the needle sometimes obscures the x-ray I removed it. After the pictures were taken I pondered whether to reinsert the needle and withdraw the dye. There are two schools of thought. The English usually leave the dye in. But here, and now I know why, the practice is to consider the dye a foreign body, and remove the dye. Anyway, the lesion proved to be a disk and I removed it. The patient didn’t do too well. After an initial period of apparent recovery his pains started again, with definite nerve root problems, radiation of pain, loss of function. I figured he had unstable back or perhaps even another disk.” Lapius was listening sympathetically. “Was it?” he prodded. “We’ll never know. He never came back.” “Went to another doctor?” “No. To a lawyer. The lawyer, this same Gautier, sent him to another doctor, a radiologist. The x-rays showed dye in the spinal column and they are suing me now.” “On what grounds?” “On the grounds that the dye caused the subsequent pains. They say he probably has an arachnoiditis, and that it was due to the dye I left in.” “Ridiculous,” I interjected. “They’ll never be able to prove that.” “They don’t have to prove it,” said Lapius. “All they have to do is to get a jury to believe it. That should be easy with Gautier hammering at the jury, pointing to the x-rays set up on a light box in the courtroom, where everyone will be able to see the white dye in the spinal column. Then there will be a few experts to sonorously pronounce the dangers of retained dye. Pes, I think you are in for a bad time.” “Frankly, Lapius, that case is only half the problem. It’s the other case I’m worried about.” “The other case! Harry, get poor Pes another drink. Quickly.” Pes didn’t wait for the refill. “When the next disk came along I became canny. I introduced the dye at a higher level so I could leave the needle in, without its interfering with the x-rays, so I could remove the dye. That’s better than repeating the lumbar puncture to try to get the dye out. Sure enough the fellow had a demonstrable disk, and I spent the next hour removing the dye. Of course a few times I pulled a nerve trunk against the needle point, and caused some sharp but temporary radiation’s of pain.” “I presume you retrieved all the dye, Pes?” “Absolutely every drop.” “Admirable.” “That’s what I thought. But after surgery the patient continued to have back pain. He tried to get in touch with me but I was at a meeting in California. He went to another orthopod who told him that trying to take the dye out was traumatic and could induce nerve injury. That he always left the dye in.” “Did the other doctor have any constructive recommendations other than that?” “Sure. He introduced him to Gautier. It turns out he’s one of Gautier’s experts. He will testify against me.” Lapius whistled. “Let me get this straight, Pes. You are being sued by Gautier for two cases. One because you damaged the patient by leaving the dye in and the other because you damaged the patient by removing the dye.” “Correct.” “What do you want me to do?” “I thought maybe you could testify in my behalf.” “Which case?” “Both. I want you to say in one case that it is preferable to leave the dye in, and in the other that it is preferable to remove it.” Lapius brooded over that for a moment. “I can’t do that Pes. Maybe I’ll do you one better, though. I’ll be willing to testify that arachnoiditis can be caused by the lumbar puncture itself, that the back pain can be the result of the original condition, that surgery is no guarantee of cure in all cases. That’s the best I can do for you.” “I’ll take it. And thanks a lot Simon.” Lapius was melancholy. “I don’t like to see medicine prostituted by third parties. More and more doctors are forced to practice defensively, so that the patient’s welfare is diluted by all sorts of considerations that have nothing to do with the case. Because lawyers stand in the wings ready to pounce on the one case in ten thousand that gets arachnoiditis if the dye is left in place, doctors like poor Pes Planus have to do handsprings to get the dye out, and in so doing, perhaps cause more damage than if he didn’t bother. It’s getting so a doctor can no longer concentrate on what he’s doing for a patient, but rather must consider how his procedure will stand up on a court of law.” The phone rang. I answered. “It’s Gautier, Simon. He fell down a flight of stairs and thinks he broke his ankle. Wants to know can you recommend a good bone doctor.” “Tell him to stay put. I’ll send one over right away.”
You Can’t Even Get Diagnosed We Have Run Out of Diagnoses Daily Observer August 24, 1973
Lapius struggled into the house, wiped the summer sweat from his brow, staggered to the medicine cabinet and extracted a bottle of fine scotch. Scotch alone would cure his staggers, a condition brought on, he confided in me, by tensions of the outer world. “How was your day?” I asked. He glared malevolently. “The country is in terrible trouble, Harry---“ “That can be cured only by spiritus fermenti,” I completed the sentence. “No it won’t cure the country, but it will soften my reaction to it.” He sipped and sighed, and sat down heavily in the wing chair. “America, the land of plenty! We are a nation of shortages. It’s absolutely unbelievable Harry. On the way to the hospital I decided to fill the gas tank. The service station manager cleaned my windshield, filled my battery, checked the oil, and waved goodbye to me. They were out of gasoline. I pleaded with him, Harry, and finally persuaded him to donate a gallon from his personal supplies. Then I stopped at the stationers for some manila folders, but they were out of them. ‘Back order for two months’ they told me. I enquired about the new desk I had purchased. ‘Possibly December. Walnut is hard to get. Matter of fact a walnut tree is worth about $15,000. If you have any walnut trees you better put a burglar alarm on them.’” Lapius stopped only to long enough to down the scotch in one measured dose. “We don’t have any walnut trees, do we Harry?” I assured him we didn’t. “Then I asked for a refill for my ballpoint pen, and they told me that the manufacturer had discontinued the line. Here I had wasted almost an hour of precious time and had accomplished zilch. However, I still had to go to the bank to arrange for a loan. But Dillingham met me at the front door, and turned me away. ‘Sorry Lapius,’ he said. We’ve run out of money. But it’s only temporary, you understand. Come back next month.’” “Wow. That sounds like a hard day,” I sympathized. “That’s only the beginning, Harry.” “How could it get any worst?” “The office,” he murmured diffidently. He was a man clearly beaten down by events. “How could it be worse at the office?” I asked. “After all, a physician’s office is his bastion. Nothing can be allowed to go wrong at the office.” “That’s what I always thought, Harry, but I was wrong. When I got to the office Persephine, my secretary met me in tears.” “’What’s troubling you?’ I asked, ‘surely it can’t be that time of the month again, so soon.’” “’It’s not that at all,’ she whined, ‘It’s that our supplies haven’t arrived.’ “’Is that all that’s bothering you?’ I said, chummying her a little to make her feel better. ‘Care not. We’ll make do. We have spare scissors, gauze, alcohol, cotton balls. After all it isn’t the first time we’ve been caught short.’” ‘It’s not that,’ she cried, ‘it’s the diagnoses. They were supposed to be here last week. Then when they didn’t arrive we were promised that they would be here definitely today. But I called the company and they said there would be a slight delay.’ ‘The diagnoses! You mean we are all out of diagnoses? Impossible. I had a closet full last week.’ ‘I know,’ she whinnied loyally, ‘but we were so busy, you used them all up. There are only three or four left, mostly liver and kidney, and you know how seldom you need those.’ ‘Check again,’ I ordered firmly. ‘Surely there must be a few heart and lung and ear, nose and throat diagnoses around.’ She shook her head. ‘Not a one. I’ve already checked. The Diagnostic Corporation told us that if you would be willing to pay double fees, they could hand deliver a few of their spares to tide you over. But that’s the best they could do.’ “I agreed to the invidious blackmail Harry. What else could I do? Within an hour their truck rolled up and they delivered a pitifully small array of diagnoses, under armed guard. I should have opened the package before he left. I would have returned them. Look what they sent me, a medulloblastoma, a pheochromocytoma, and erythema multiforme bullosum, and a lupus erythematosis.” “What a crazy assortment. You wouldn’t use those in your office practice in a million years. What will you do, send them back?” “No. I’ll keep them around for some clinical-pathological conferences we have at the hospital. But lo and behold, who was seated in my waiting room, but Dillingham the bank president. I ushered him into my examining room. His face was puffy, he could scarcely talk, he kept pointing to his throat. I peered in and saw the reddened most infected tonsils I’d seen in ages. ‘Sorry, old man,’ I said to him, ‘you’ve sure got lousy looking tonsils but I can’t help you. You see, I’ve run out of diagnoses. “He grasped his throat. ‘You’ve got to help me. I’m strangling, I can’t eat.’ ‘I’d sure like to help you, old man, but it’s out of my hands.’ ‘Can’t you just give me some penicillin?’ he gasped. ‘Not without a diagnosis. You wouldn’t want me to treat you blindly, would you? He shook his head. ‘Just put some ice on your neck and call me next week.’ ‘I’ll be dead by next week.’ “Amazing, Lapius,” I said. “Whatever happened to the diagnoses to make them in such short supply?” “Well, as I explained to Dillingham, when the dollar dropped, the Germans and Japanese to say nothing of the French, found they could buy our diagnoses cheaply. They bought several billion dollars worth and left us on the ropes, diagnostically that is.” “So the day was a total loss,” I said. “Not completely,” Lapius replied, lighting a cigar. “The president of the bank said that if I could treat his tonsillitis he thought he might squeeze my loan out of the bank. So I gave him some penicillin and got the loan.” “But I thought you said you didn’t have any diagnoses left.” “I didn’t. But then Dillingham was the one who made diagnosis. He called it tonsillitis. It seems that his bank had bought some diagnoses cheap with Eurodollars. They helped corner the market and create the shortage of diagnoses and drive the domestic price up. As it turned out, the president of the bank now owns most of the diagnoses in the area.” “What is he going to do with them?” “Probably use them to become a member of the board of trustees at the hospital.”
The Medicaid Game Daily Observer August 31, 1973
Rigid Rules are Counterproductive. How Rigid can the Rules Be?
I arrived at Lapius’s office just after he saw his last patient for the day. He was busy plucking at the small portable typewriter he kept near his desk. The staccato sounds beat an unsteady rhythm until he had finished the letter. Only then did he greet me. “Hello, Harry,” without looking up. “Here, read these. They will bring you up to date on the final letter of my correspondence, the one I’ve just finished.” He handed me a sheaf of papers. “They are in chronological order.” I started to read. The first was from Lapius to Medicaid. Gentlemen: I have a patient who has just been deprived of his Medicaid privilege. It seems that at your urging, he got a job which boosts him above the minimum for Medicaid by $100 yearly. He is an asthmatic and requires weekly injections of pollens for desensitization. Without these his asthma is so severe as to prevent him from working. When he can’t work he goes on Medicaid. When on Medicaid he can afford the injections that make him better and so, able to work. When he gets a job he is taken off Medicaid and he can’t afford the shots. I offer them to him for nothing, but he refuses, saying he doesn’t like to be in debt to anyone. Without the shots his asthma returns and he has to quit his job. This makes him eligible for Medicaid again. Is there anyway out of this dilemma?” Sincerely yours, S.Q. Lapius, M.D. The answer was as follows, Dearest Provider: If your patient earns even $1.00 more than the minimum, he is no longer entitled to Medicaid. Sincerely yours, Ms. Eloise Smythe Dearest Ms. Eloise Smythe: Your compassionate letter touched me deeply. However, although it answers my question, it doesn’t solve the problem of how I can provide medical care for my patient. Is there not some way in which the patient can be given a limited Medicaid allotment for his asthma desensitization shots. After all he only earns $100 over the minimum. It costs him $150.00 yearly for the shots. This in reality brings him below the minimum. Can Medicaid find $150.00 for this patient so he can remain gainfully employed? Sincerely, S.Q. Lapius, M. D. Dear Provider: I have already explained to you that the patient to whom you refer is above our minimum-earning rate. If he is no longer able to work, he can return to Medicaid. In order for him to return to Welfare rolls, you will have to fill out the five-page form (enclosed). Sincerely yours, Ms. Smythe Dear Ms. Smythe: We seem to be going in circles. Is there someone there who has more of a grasp of the medical situation involved with whom I might correspond. Am returning the five-page form (enclosed) since there is no point in filling them out because the patient is still above the minimum. Yrs. Truly S.Q. Lapius, M.D. Dear Provider: I refer you to my superior, Ms. Snyder. She is the secretary to the manager of the unfilled Medicaid claims department and I am sure she will be able to answer your letter. Truly yrs. Ms. Smythe Dear Ms. Snyder: Enclosed is correspondence to from Ms. Smythe. Can you help me in this matter. Please note that now it takes a 16-cent stamp to forward the material. Sincerely yours, S. Q. Lapius, M.D. Dear Provider: Statutes relating to your patient are enclosed. I hope they will be of assistance to you. Please to us if we can help you in any way with your problems. Sincerely yours, Ms. Smythe for Ms. Snyder Dear Ms. Snyder-Smythe: Thank you for the clarification. I read the statutes carefully. Is there any way to get around them. After all, for an investment of about $150 yearly the United States Government could save about $1000 in medical fees and an additional several thousand dollars in maintenance fees. This represents a profit of about four thousand percent. Incidentally, is there a higher up who could help circumvent the law? Your obedient servant, S.Q. Lapius, M.D. Dear Provider: Yes. You could write to the director of the entire State program. Ms. Martin Milgrim. Sincerely, Ms. Smythe for Ms. Snyder Dear Ms. Martin Milgrim: Enclosed is the correspondence between myself and your office. Can you help to find a reasonable way out of this dilemma. S.Q. Lapius, M.D. Dear Provider: No, Sincerely, Ms. Smythe for Ms. Martin Milgrim through Ms. Snyder Dear Ms. Mss. Smythe, Snyder and Milgrim: Would you be kind enough to note that my name is Simon Quentin Lapius, BA. LLD. PhD DsC MD Dear Provider: The code of our statutes prohibits us from discriminating. You are a provider, no different than any other provider of Health Care. Sincerely, Ms. Smythe for Ms. Martin Milgrim, through Ms. Snyder Dear Ms. Smythe et al. Is there a higher authority in charge of this mish mash whom I might make this appeal? DOCTOR SIMON QUENTIN LAPIUS Dear Provider: God knows. Sincerely, Ms. Smythe “Well,” I sighed, turning to Lapius. “That’s quite an informative correspondence. What are you going to do now?” “Take it to a higher authority,” he said, handing me the letter he had just finished typing—addressed to: God, % Prudential Insurance Company Dear God: Sorry to have to bother you, but this correspondence was bucked upstairs. Would you please review it and tell me whether there isn’t some way that a common sense solution can be found to the stated problem. Sincerely yours, your obedient servant, Simon, Quentin Lapius, M.D. One week later Lapius showed me the answer to his last letter. Dear Provider: As you must know by now, I don’t make the law. It is made in my name by mortals. I am merely the enforcer. Most sincerely yours, God, (signed by Ms. Smythe)
The Efficiency of Medical Wards Daily Observer September 7, 1973 No sooner had I stepped into the foyer, water pouring from the brim of my hat, than Lapius called, “Here Harry, help me with these.” He was bent nearly double on the little bench trying to fit galoshes over his size 14 E shoes. “You should buy galoshes one size larger than your shoes, Simon. It would be easier. Or better yet, get some boots that you can step into instead of your shoes. Anyway, where are you going? It’s pouring out.” “We are going to the hospital to see Frank Wrong.” “What’s with him?” “He’s been in for a week. Recuperating from pneumonia. I just learned about it today.” “Why do you need me. I don’t know him.” “That’s just the point. You’ll get a chance to meet him. Frank Lloyd Wrong is one of the important architects of the city. In fact, he designed the hospital we are going to. You know, Metropolitan.” “Gad. That’s an architectural horror.” “I know. I told him so when he designed it. Let’s go. It will give me a chance to gloat,” Lapius said gallantly. I squeezed the water off my hat, replaced it on my head, and opened the door. Lapius was jumping up and down to wedge his heels into the galoshes and in a moment we were off to the open road. Metropolitan was an endless maze of elongated wings. When we finally found the entrance, Lapius inquired at the desk and found that Wrong was in room 714. The elevator stopped on every floor on the way down and after having picked us up, stopped at every floor on the way up. After about 15 minutes we were disgorged on the seventh floor, then followed a series of arrows and signs till we finally located the corridor that led to room 714. Wrong was bedded down in one of the two beds in the room. The only problem was that his roommate had visitors and Wrong himself had some other friends there, so that the scene resembled bustling crowds at a cocktail party, except that no redeeming cocktails were served. Several of the visitors were smoking, and others were coughing. Finally we got to the bedside. Wrong was almost recovered, lying in bed in his dressing gown. He welcomed us with a bright smile, and would have bounced off the bed to greet us but there wasn’t anymore standing room. “Frank, it’s good to see you,” Lapius said beaming. “You appear to be fully recovered. Thank goodness for that.” Then he introduced me After the amenities Lapius said, “Well now, how do you feel about being a patient, after having designed so many hospitals.” “They took very good care of me, Simon. I’m fully recovered, as you can see. The only thing,” he lowered his voice to a whisper, “it gets crowded around visiting hours. But it was quite an experience. I’ve had three roommates already. The first one died the day after I arrived. That was scary. Particularly since I wasn’t too sure I’d make it myself. Then, as I was starting to recover, they put a fellow in here who had severe colitis. You know he couldn’t do a thing for himself. Weak, dehydrated, and solutions being fed into his veins all day. He was sort of pinned to the bed. Helpless. So, you know, I sort of had to help out. The first night was rough. I was up and down all night getting him bedpans. But after a while I worked out a routine and took pretty good care of him. He finally made it. But oh, the few times he had accidents in bed. Sometimes he was incontinent. The stench was overpowering.” “How’s your new roommate?” “Oh, he’s fine. I’m finally getting some rest. But I made it despite all the nursing I had to do.” “Tell me Frank,” Lapius urged, “Why did you have to do all the work? Where were the nurses?” “You know how it is at night, Simon, in a hospital. There is a skeleton staff, and the skeletons were in other closets. You can’t get a nurse just anytime you want.” “Can’t you ring for them?” “Sure. But suppose they are in other rooms taking care of sick people. They might be a hundred yards from their desk, so by the time they get back and see the flasher, a lot can happen.” “I guess your right Frank. Well, old boy. Good to see you recovered. We’ll get together as soon as you get out.” We said good bye. Back at the apartment Lapius had just as much trouble getting out of his galoshes as he did getting into them. I helped him get them off riding-boot style. “We must have some brandy to get the chill off, Harry, eh?” I fixed two, and we relaxed. “Hospital design these days is preposterous,” Lapius said, after warming to the first sip of the amber Napoleon. “Semi-private rooms. That’s a humbug, Harry. How can anything be semi-private? It’s either private or not private. A semi-private room could more accurately be called semi-public.” “What would you suggest. A hospital of private rooms, only one patient to a room?” “Ridiculous. No what I would suggest is a return to the ward system. In today’s hospital most of the space is devoted to halls with wards, most of the space would be utilized by patients. But more important, the patients would be congregated where nurses could see them. Even the skeleton staff would be adequate for emergencies. Hospital cost per patient bed would be cut about ten-fold. Everything, including patient care would be infinitely more efficient than it is in the semi-private system.” “Ugh,” I said. “Wards were dirty and crowded.” “Semi-private rooms are dirty and crowded too. Here look at this,” Lapius rummaged through a drawer and withdrew a print of an old monastic hospital. The patients were distributed in alcoves, each guarded by a curtain, along the four walls, and the nurses' station was in the center of the great hall. “Look at that, Harry. A much better plan than the current monstrosities with endless corridors, each patient hidden from the nurse. And that picture represents a hospital in the 16th century.” “But people don’t like to be crowded together in a ward. They like privacy.” “Did Wrong have privacy? He spent half the night nursing his roommate. In a ward camaraderie develops. There are always healthy ambulatory patients about to be discharged who will help the sick. There is always someone who can fetch a nurse or doctor in case of emergency. But Wrong had to help his roommate even when he was running a 102 fever, simply because he was the healthier of the two. That condition wouldn’t exist on a ward. Today they could build wards with numerous semi-private bathrooms. Wards could be designed for dignity and comfort.” “If ward-plan hospitals are more efficient, less costly to build and service, and equally comfortable for patients, why do they persist in building semi-private?” “Because of Blue Cross, which promised to pay for semi-private accommodations in hospitals. That was when wards were for the indigent. But with hospital costs what they are with semi-private accommodations 50-100 dollars a day, we’ll all be indigent again in no time. We should forestall that by going back to the ward system.” The phone rang and Lapius had a protracted conversation. “That was Frank Lloyd Wrong,” Lapius said. “He says that his stay in the hospital has stimulated his thinking in the design of hospitals. He says he has some great ideas.” “Don’t tell me he wants to design ward hospitals?” “No. All private rooms,” said Lapius morosely.
Weed’s Problem Oriented System of Medical Record Keeping Daily Observer September 14, 1973
S.Q. Lapius was at the blackboard in his study. He ignored my hello, didn’t even turn his back. “Hard day?” I asked. No answer. “Anything bothering you?” I said in a louder voice. Naught to be heard but the squeaking of chalk on the board, and the distant humming sound, like katydids in the brush that Lapius emitted when lost in concentration. I gave up and went to the kitchen, clinked some ice in a short glass, and poured some gin, in the process of making myself a martini, when Lapius woke up. His voice bored in from the den. “Make one for me too, will you Harry, like a good fellow.” I did, but had finished half of mine before he emerged from his caverns of thought. He sipped the drink and nodded approvingly, then said, “Yes, no.” “Yes, no, what?” I asked puzzled. “The answers to the questions you asked when you burst in.” “I didn’t think you had heard.” “I always hear, Harry. I don’t always answer. Actually I was transferring some case histories into Weeds terminology, you know, the problem oriented record.” “I’ve heard about it. How did it go?” “Not bad. You know what Weed says. He feels that doctors are scientists, and that good records are basic to good science. He feels that science demands precise thought and logical pursuit, so he has devised the problem oriented system to deal with a medical record.” “I’ve seen some of his work. I guess there’s some advantage to it, but I don’t see it as much more than changing the term ‘diagnosis’ to problems. After all, when a doctor gets through taking a history, he lists the diagnosis. Weed would have him list the problems, number them, and then refer to the problems by number in follow up notes.” “It is more sophisticated than that. In addition to the problems listed, there must be a plan for managing each of the problems. If a patient has chest pain, belching, is a heavy smoker, and drinks too much, these would be listed as problems from 1 to 4. Then in the follow-up, there would be a plan to deal with each of the problems, and finally, the progress with each problem would also be categorized accordingly. Of course it would lend itself to computerized data collection on a population basis, if each doctor accomplished the task according to the precision that Weed would like.” “The doctors will be working for Weed, so he can correlate all the data for the problems of a given population?” “Harry, you are young and cynical.” “Maybe. But I get skeptical of all plans that tend to unite patients into population groups.” “Don’t be. There is much good in the Weed method. Principally it would help to correct one of the grievous flaws in medical record keeping. For instance, Weed proposes a flow sheet, a crosshatched page which would list the medical parameters, such as lab work, pulse, blood pressure, and more sophisticated data, in columns, so that the changes in these values during a given period of time, and perhaps treatment, can be compared. Look at the average hospital form now, with it’s hodgepodge of laboratory data pasted in random fashion to pages wedged into the metal chart holder. It is impossible to get a clear-cut idea of how the same data progresses from day to day. Weed is asking for order in the record keeping, so that it has coherence, and develops a theme.” “I take it you favor this Weed system.” “Not entirely,” Lapius said, sipping slowly at the martini. “Simon, you are doing mental cartwheels. You just about sold me on its merits. Now you’ve spun off. Is the martini too strong?” “Maybe it’s nostalgia, Harry, but I still feel some addiction to the old method. Talk to the patient, get a medical history, present illness, past illness, review of systems, family history. It’s all there. Weed doesn’t add to it, but just promises to organize it better. The trouble is that Weed promises to revolutionize medicine with it. He’s at the University of Vermont now where he has computerized his system. He feels that it will serve as a model for the computer led revolution in medical care.” “Aha, Simon, I told you so. These guys come along and create new systems that lump everybody together, and then they have visions of becoming health czars of some such thing.” “Why imply base motives, Harry?” “Not base, Simon, simply subconscious motives. Anyway, how does the Weed system progress?” “Well, of course, a lot of schools have adopted it but also it is meeting resistance, from the traditionalists in medicine. Weed says ‘—who are the people less likely to accept a new a ballgame? The people who were magnificent in the old ball game. The people who could memorize a lot, the people who became professors --. We’ve got to take memory-dependence out of the system.’ “Of course Weed goes further,” Lapius continued. “He feels that his system will be perfect for peer review and medical audit. After a while he sounds like a functionary setting up systems whereby the performance of doctors can be audited and compared. This worries me. The concept of reviewing a doctor’s efficiency slowly is being institutionalized. It sounds good, but in the long run it is I feel, dangerous. First it casts a slur on the physicians as a group, and sets up systems and precedents where the subtleties of medical practice will be evaluated by a computer a rule book and a clerk.” “So now you are against Weed?” “Perhaps I am against what I think Weed wants to be. I am also against measures that depersonalize medicine, because fundamentally you can’t just put people into some medical equivalent of a McCormack Reaper, separate components, and reassemble them again. This doesn’t solve the problems of patients, nor does it assuage their fears. But it probably would not be a bad idea to adopt into our record keeping some of the organization inherent in Weed’s concepts. Weed is not telling us anything new. What has actually happened, is that the process of medical diagnosis has become more complex, as has treatment, even as it has become more effective. I think it is true that doctors take less time with each patient than they did in the past, and Weed has insisted on a new system to adapt to this change. Perhaps the old system was just as good. Maybe doctors should slow down a little and use it, with some minor modifications. The fact is, that although all of us have problems in common, each patient has problems in particular, and in a computerized system, these might get short shrift.” “I’m not sure I see what you mean.” “Simple, Harry. In the problem-oriented system, I say to you that I have a problem. You note it and ask me what it is. I tell you I need another martini. Of course you’ll make one for me, and duly note the fact that you’ve solved the problem. But in the traditional medical system, we’ll chat a bit, and you’ll graciously ask me whether I would like another martini. The end result might be the same, but in medicine, as in life it is the approach that counts.” “Simon,” I said companionably, “Would you like another Martini?” “No thank you Harry. I’ve had enough.”
Weed anticipated and in part created methods for medical record computerization, just now coming into vogue.
Legalize Drugs Daily Observer September 21, 1973 Drugs Used to ‘Help’ Instead of Hinder S.Q. Lapius was polishing a long black stick capped by an ivory knob carved to the likeness of a bulldog. “Where did you get that?” I asked admiring its pristine contours. “I’ve had it for years. It’s a cane. I’ve resurrected it from an attic of stored relics.” “Did you damage your foot? Has the gout returned?” “Nothing like that, Harry. I decided that I needed a walking companion, for which, these days, there would seem to be nothing more suitable than an old fashioned walking stick.” “You are not hinting darkly that you intend to use it as a weapon, are you?” I asked suspiciously. “Yes Harry, but for defense only, mind you.” “That seems extreme, doesn’t it?” “Does it. It’s better than carrying a sword, which is what people will probably be arming themselves with if the city continues to be dangerous.” “What brought on this sudden concern for your safety?” “Gautier. He was felled by some drug-crazed felon. Whacked on the noggin and robbed.” “Is he okay?” “Of course he is okay. Gautier is a lawyer, a breed noted for steel-trap minds, skulls that can be penetrated by nothing less than armour piercing shells. But nonetheless he suffers occasional headaches and bright lights dance before his eyes although he says they are becoming dimmer.” “It’s a terrible state of affairs,” I admitted. “Of course it is. The government ought to start dealing with the drug epidemic in a more realistic manner. You know, if they would look into it instead of running away from it, some good might come of their investigations.” “What would you suggest?” “For starters, the pragmatic approach of the English seems to have a borne fruit. They give heroin to drug addicts. They have centers where addicts can get their fixes, for nothing.” “That doesn’t cure the addicts, it perpetuates their habit.” “Yes but it keeps them off the streets, relieves them of the burden of having to steal enough money to buy their drugs, and thereby reduces the crime rate.” “Don’t you think a program like that is sort of giving a stamp of approval to drug addiction. It might even spread the habit.” “On the contrary. The habit has spread anyway. But it does take the traffic in drugs out of criminal hands. Of course they should go one step further, which would be to provide sanitaria for the addicts. Nice places in warm climates where they could take their fixes and repose under the shade trees and meditate.” “No government is going to pamper drug addicts; reward them for their dereliction.” “Of course not, Harry. But it’s a good idea and would get them off the streets. As society became more civilized, pedestrians sheathed their swords, hid them in canes, carried canes only, and finally dispensed with walking sticks altogether. The trend seems to be reversing, and we are going to our weapons again. Besides, if governments stopped acting as if they were so afraid of drugs, they might be able to use them to good advantage. Once they could be dispensed legally to addicts, some might be used medically.” “But we do use them medically.” “Mainly for pain, Harry. But it occurs to me that the use might be extended to mental anguish.” “We have tranquilizers, don’t we?” “Yes,” Lapius mused. “But I was thinking of drugs like LSD and its like, which might be offered in some controlled form to the hopelessly ill, the slowly dying patients, whose bleak lives must cause nothing but daily repetitions of mental anguish.” “You mean make drug addicts of the chronically ill?” “Well, offer them the opportunity, anyway.” “But Simon, you will be robbing them of their free will, their freedom of expression. You will be obtunding their minds. You will deprive them of the opportunity to come to an agreement with death, to accommodate their morality.” “Perhaps. But on the other hand it might simply hasten the religious experience, do away with fear and self-pity, bring them to realms of mind-expansion they never knew existed before. After all, Holmes sniffed cocaine, DeQuincy, Coleridge, and possibly Byron, perhaps even the young Chatterton, were under the influence of laudanum when they wrote their most inspired works. Why not offer these pleasures to patients who are the unwilling prisoners of paralysis, bed-fast arthritics, the victims of injury and neuromuscular wasting who realistically can hope for no release other than death. “By God, we’re cruel,” Lapius expostulated. “We put them into the sterile, managed atmosphere of nursing homes where they are ministered by strangers, and even deny them the simple dreamy pleasures of alcohol. We do this for our loved ones, consider how we would treat our enemies.” Lapius had finished polishing his walking stick. He brandished it in the air and took a few practice swings. “There, that seems suitable. No one will threaten me tonight, not while I have this with me. See you later.” “Are you going to take a walk?” “Of course not, Harry. Call me a cab, like a good fellow.” Lapius was correct 30 years ago and is correct in this era. Would it be wrong to offer euphoria to the pain ridden or dying?
Simple ArbitrationDaily Observer September 28, 1973
Administration Strangles Freedom
“You seem engrossed, Harry,” Lapius muttered. I dropped the newspaper. Lapius was in a conversational mood that would not permit me the luxury of silent concentration. “Sure I’m engrossed. This Watergate affair. Politics sure is a dirty business.” “On the contrary my dear boy, it’s a glorious business.”” I was aghast. “I am aghast,” I said. “In the light of these disclosures how can you make a statement like that?” “They caught the scoundrels, didn’t they?” “Most of them,” I admitted. “But they don’t always catch them.” “Remember, Harry, you can’t fool all of the people all of the time.” “But if you fool all of them just once, that’s the ball game. You can kiss the country goodbye.” Lapius slammed his jaws tightly, preparing to issue a definitive statement. “The country is safe as long as there’s a free press. Actually, Harry, I have a lot of faith in the political process. It is turbulent and encourages conflict. Paradoxically, the real danger to the country resides in the nature of Congress.” Lapius was shifting ground too fast. “How about Disneyland?” I asked. “Don’t be coy,” he admonished. “I say Congress because they establish administrative programs, and it is the administrative system that is choking the country, stifling its freedom. Administration is the opposite of politics. It is harsh and violent. It permits no conflict. The more programs Congress establishes the less freedom we have. What once was accomplished by the tug of war between political pressure groups become rigidified in a set of rules. The rules throw the system out of gear. They replace reason. They replace the pitched battles of the body politic.” “Come on Simon. You’re pulling my leg. Look how corrupt politics is.” “Of course it’s corrupt; - corruption on all sides. That’s what gives the political system balance.” “But look at the excess.” “They balance out, bless them. Excesses to the left and to the right oscillate finally somewhere near the center. Corruptions cancel each other. Administration, on the other hand while not itself corrupt, is corrupting. This is because an administrative program can only be satisfied by a written record. Since the requirements of a program are known in advance, people running the program find it compelling to contrive records that satisfy these requirements. It would be silly of them to do otherwise. In addition, the administrative system has no watchdog –.” “But you just praised the free press --.” “Humbug. The press watches only the big events in the large arenas. It can’t involve itself with all the minutiae --.” Lapius stopped short and emitted a sigh of exasperation that zephyr-like, threatened to blow out the pilot in the stove. “Harry, do you realize what percentage of our lives is conducted under administrative codes administered by administrators? By God, it’s a whole new profession to be an administrator. What was it William Shannon wrote--?” After eating, Lapius was usually too bloated to bestir himself. “There Harry, on my desk under the blotter. I clipped it but hadn’t filed it yet. Get it for me like a good lad.” I trotted obediently for the clipping and returned with it between my teeth. “Here’s what Shannon wrote.” Lapius adjusted his bifocals and started to read. “Men and women who cannot teach physics or Greek or history, who cannot heal a sick child or build a bridge or write a poem, such person often find a living in the intellectual wasteland of educational administration.” “Of course,” Lapius continued, “Shannon referred to education, but it applies to administration in general.” “Simon,” I tut-tutted, “You are prejudiced.” “Not only prejudiced, Harry, but intolerant. Take a simple example of an administered enterprise, a hospital. You are familiar with hospitals, doctor, are you not?” he asked bitingly. I ignored the thrust. “Look at the conspiracy of corruption that exists in a hospital.” I looked but couldn’t see anything. “Aren’t you called to the record room to complete charts, doctor, under threat of having your privileges taken away? Don’t you have to insert signatures that have been omitted, cover orders written by a resident physician in your absence, write final notes on patients that died in the middle of the night while you were sleeping?” “Of course, but that’s just to satisfy requirements of the Joint Commission for Accreditation of Hospitals (JCAH) and the state inspection committees, that charts be completed.” “Precisely. But the assumption is that all this was done while the patient was still in the hospital. The true representation of the fact is the appearance of the chart when the patient leaves the hospital. To certify a medication you didn’t even know had been administered is fraudulent, yet there is collusion between all parties, the accreditation committees to alter a record in order to satisfy some administrative statute.” “But the statute is unrealistic.” “Of course it is. But how can you change it to conform to reality.” “Go to the board of directors,” I suggested lamely. “The board of directors! They won’t change a light bulb unless it is permitted in the hospital code. They are simply an anonymous corporate body established to insure that the hospital runs properly according to law.” “What’s wrong with that?” “Everything. The law isn’t a sick patient. The law isn’t a tray of cold food, an overheated room, a hard bench in the emergency room, an understaffed nursing station. The law isn’t human. True, laws are written to insure the welfare of the patient, but administrators are trained to look to the law rather than the patient.” “What would you suggest?” “Conflict, Harry. Conflict between a strong medical staff, a cohesive staff of employees and the administration, where criticism can fly back and forth without reprisal. A tripartite system of equal powers all dedicated to the welfare of the patient. The individual must be supreme.” “But in our society no individual is above the law.” s “The patient is an exception. The law must be bent in behalf of his welfare.” “Suppose there’s a deadlock between these three equal power.” “Then take it to arbitration. Politicize the system. Give it some freedom.” “Simon,” I said yawning, “I’m tired. I’m going to bed.” “You are not,” he thundered, “I’m not finished yet.” “Simon. To whom can I take this matter of my going to bed for arbitration?” “All right, go to bed,” he grumbled.
Chronic WasteDaily Observer October 5, 1973
Mandatory Monthly Medicaid Visits Are a Chronic Waste
I barged in, after slamming the door shut. “You seem vexed, Harry,” S.Q. Lapius muttered pleasantly. “What makes you think that, Simon? The manner in which I slammed the door shut?” “Not at all dear boy. It was the way the windows rattled after you had slammed the door shut that clued me in. Difficult case, I suppose?” “Not really. No as a matter of fact it was an easy day,” I said leaning back on the stuffed chair and stretching my legs full length. “As a matter of fact I spent a good part of it going over the Medicaid cases at the nursing home.” “No insoluble problems there, I should imagine,” Lapius remarked absently. He was starting to busy himself with the newspaper. “Of course not. Chronic disease medicine is a housekeeping problem by and large. But, instead of having the nursing home call me when the patients become acutely ill, Medicaid demands that I see each of them once a month. It’s a waste of my time, and incidentally is costly to them. I don’t see why Medicaid should make an arbitrary ruling like that. There’s no point in passing a stethoscope over the chest of these patients or poking them in the belly unless they feel sick. The ruling is capricious. It cost Medicaid thousands of dollars that could be better spent elsewhere. Medicaid has somehow arrived at the conclusion that if one of their patients is in a nursing home, they are sick enough to be seen once a month. Not once a week, not once a year, but once a month. I wonder how they arrived at that figure?” “Suppose I put up the coffee. You’ll feel better,” Lapius said soothingly. “Well don’t you think that’s dumb, Simon,” I persisted. “No.” “You don’t?” “Not really. The state is paying the medical bills for these patients. It has the right as guardian, to call in the patient’s doctor whenever it chooses. If a private family hired you to look after one of its members in a nursing home, and suggested that you look in once a month, you’d do it wouldn’t you?” “What for. Why drop in unless the patient is sick?” “But if they really wanted you to do this and offered you an exorbitant fee, then you would do it without complaint, right?” “Of course, if they made it worth my while.” “So it’s not the principle of the thing, Harry, it’s the fee.” “Not entirely. A private family who is willing to pay a large fee for a monthly visit will go along with all my recommendations regardless of cost. Here is where Medicaid differs. They hold back in some area. In other words, you don’t have carte blanche.” “Harry,” Lapius laughed. “Where does anyone have carte blanche? Unless they carry an American Express card or some such thing.” “The thing that bothers me isn’t so much the monthly visit, Simon. But it’s meaningless. Actually, the best way to monitor patients in a nursing home is to have a survey of laboratory tests done automatically on a quarterly or semi-annually basis. I can’t tell on my monthly visit whether the patient is starting to get an anemia, urinary infection, or whether some other insidious metabolic problem is developing. The better way of spending the Medicaid monies, rather than the useless monthly visit, would be a laboratory survey, with the proviso that the doctor is informed of the results of the testing. As a matter of fact, with all the hubbub about Health Maintenance Organizations, it’s the nursing homes that would lend themselves best to medical health screening. A lot of time and money could be saved.” “Harry, you’re discarding the mystique of the doctor in a very cavalier way. It’s comforting for these patients to know that their doctor is looking in on them, even if it serves no other purpose, at frequent intervals. It gives the patient a sense of security. There’s nothing wrong with the chemistry survey, but I don’t think that the doctors’ visits should be stopped.” I wasn’t convinced. “I’m going for a walk,” I told Simon, standing up and heading for the door vestibule. “Harry,” he commanded, “Just a minute,” he barged ahead of me. “What’s the trouble?” “Nothing. I just want to open and close the door for you.”
Doctor Becomes a ProviderDaily Observer October 12, 1973 Now You Are Doctor Provider but No Longer in Control of Your Profession --- S.Q. Lapius addressed the graduating class of his medical school. “It is ordinarily a privilege for a member of one generation to address representatives of another, to welcome them across the gap of years as successors in medicine, the noblest of professions. In the past, alumni could look forward to the pleasure of accepting new graduates in to the profession with certain knowledge that the generation gap was relatively insignificant. This, alas, is no longer true. The medical tradition, based since the time of Hippocrates on the sacred trust of the doctor-patient relationship, is no longer intact, and in fact is so distorted that the new graduate may find himself in a terra incognita for which he is entirely unprepared by his medical curriculum. “When I entered medicine I had no doubt that all the skill I could acquire would be placed at the service of my patients. In what other profession does a stranger walk into an office and lay bare his soul and body with the faith and implicit trust that a M.D. degree evokes? This act of faith by the patient has been earned by doctors throughout the long tradition of their art. The professional and ethical standards of the medical profession have guaranteed to the public the highest standards of excellence, of proficiency, of compassion. To whom other than the closest relative would a person entrust himself on deathbed? Or an operating table? Yet patients continually put this trust in strangers for no other reason than the fact that the M.D. degree has proved the worth of this trust. Had medicine represented anything less than this relationship, I could never have become a doctor, nor could most members of my generation of doctors. “But things have changed and I cannot, in good faith promise you a rose garden. The roses are withering on the vine and aphids are nibbling the leaves. The profession of medicine is under attack, based on the premise that the doctor represents no more than another member of the health team. There is a movement afoot to destroy the elite position of the doctor and of his profession indeed to destroy the concept of elitism. The dictionary defines elite as “the best or most skilled member of a given social group.” Certainly, according to this definition, medicine is an elite profession. “But today you are about to enter a world where you, the doctor, the elite professional, will become subordinate in your practice to a rabble of administrators who have the authority to govern your acts as physicians, dictate the method of your practice, while leaving you, doctor, with the final responsibility. “Who, after all, becomes an administrator? Anyone who can’t build a bridge, design a building, paint a picture, compose a sonnet, heal a sick child; those devoid of any talent or ability in the particular, and no ability in the abstract, who somehow wander into the wasteland of administration, vaulting by title alone the impediments that you have had to conquer by sweat and will, concentration and sacrifice, to become your superiors in a field which they know nothing. These individuals, be they in charge of Medicare or Medicaid, Blue Shield or Blue Cross, or any duly constituted authority concerned with health, will direct your lives, determine your fees, force you to work with the tools they supply, deny you the right to the best equipment money can buy, and, in general, define the terms under which you will practice medicine. “You will find yourself concerned more with the cost of patient care than patient care itself. You will find yourself badgered to discharge patients from hospitals before you feel they are ready to leave, or else face the opprobrium of an invisible administration whose concern for cost control threatens to disrupt the relationship between doctor and patient. The doctor in your brave new world will simply be another utility, supplying governed output for governed rates. In short, the profession of medicine is beleaguered. ”I don’t plead for the doctor. Under this new system the doctor will not be the victim. The victim will be the patient, because the fundamental doctor patient relationship has been distorted to such a degree that the patient no longer can know with certainty who, finally, will be responsible for his welfare. In whose hands does the patient now place his vital self, his well being? A doctor, a nurse, a social worker, a computer in some remote and nameless office of a government designated insurer? Will it be the hospital administrator, the board of trustees, the charge nurse or the janitor who will bring the healing arts to patient in his hour of need? “Ironically, although you are on the verge of receiving your M.D. degree that entitles you to be called ‘doctor’, health agencies will refer to you as a ‘provider’. In this respect you are lumped with all other ‘providers’ of health care, including the deliveryman who supplies linens to the hospital. “Try that on your shingle, John Doe, Provider. Welcome to the ranks and good luck.” Afterwards, I said to Lapius, “Goodness, but you were very uncompromising. Did you mean everything you said?” “I guess I did, Harry. The point is that although I can do the job of any of the providers, none but a doctor can do my job.” “You are an elitist,” I said. Lapius took out a black cigar and peered momentarily along its sleek length before answering, “I guess so, Harry. By the sweat of my brow, I’m an elitist. Any doctor who can do more for his patients than I can, is more elite than I am.” He chomped on the cigar. I struck a match. “Here, let me elite your stogie.
Psycho-Surgery Daily Observer October 29, 1973
Morality—Psychosurgery to |Change Personality
S.Q. Lapius seemed to be doodling. Suddenly he chuckled and looked up from his work. “Finished,” he exclaimed triumphantly. “Listen, see if you like it.” He stood up and bowed slightly in my direction like a student getting ready to recite before the class. Then, cocking his glasses down on his nose, started to read.
“When changing liver, lung or heart or grafting many another part It might be said to those who quiz ‘The donor was --- ‘The recipient is ---,’ But moving into new terrain They’ll soon transplant the human brain. Will it be said when this occurs, ‘The donor is --- ‘The recipient was---.’”
Lapius preened. “Do you like it?” he asked. “It rhymes,” I said non-commitently. I was annoyed he because he interrupted my snooze. “Of course it rhymes. It’s a poem. But it also raises a serious question. Suppose one were able to transplant a brain. Would the new person represent the brain or the body?” “I’m sure it will be a problem,” I said closing my eyes and trying to reenter my dreams. It seemed only a few moments before Lapius wakened me again. “Do you have any opinions on psychosurgery, Harry?” “Why the sudden interest?” I dodged the question. “Dr. Irving Cooper asked me to join a panel on the moral issues involved. You know, don’t you, that he has just come up with a new technique to inhibit intractable epilepsy by the implantation of an electrical pulsing mechanism over the cerebellum. It works, too. There is one case in particular that struck me. A young person with seizures and periodic attacks of violent behavior during which she would commit acts of mayhem. Actually stabbed several people. Now she is free of seizures, but Cooper has been attacked for having deprived her of her essential personality.” “But at least she doesn’t have to be institutionalized,” I pointed out. “True. Until Cooper operated on her she would have had to be guarded, perhaps jailed.” “Loss of some personality traits, some vitality seems a small price to pay for that freedom to stay out of jail.” “Yes. But of course the case is extreme. There can be more subtle examples. Certainly psycho-surgery raises important questions for society to answer. After all, what is the essential self? Body or brain. If you answer soul, I’ll ask you where is it situated. Does meddling with the brain affect the soul? “With some people I should think a hemorrhoidectomy might endanger the so--.” “Don’t be frivolous, Harry.” “Well, you were throwing away some light lines before--.” “Just some levity for my talk, Harry. But I don’t scoff at the questions being raised.” “I think the argument is silly,” I said. “After all, doesn’t the mental attitude of a person change when a kidney is transplanted? Until the transplant the patient might have been sick and depressed. If the transplant is successful, won’t the mood change?” “Hopefully for the better. And of course Cooper changes patients hopefully for the better too. And the psychosurgeons who at the sacrifice of some degree of alertness eliminate hyperactive aggressive activity have, it seems to me, also changed their patients for the better. But somehow, when it comes to performing surgery on the brain, particularly those parts of the brain that affect the ‘mind’ people find excuses to damn it. There are those who say that it deprives the patient of the freedom to be violent. It actually becomes a civil rights problem.” “I presume you are talking about criminals who would be offered this operation. Certainly informed consent is necessary. I don’t think it should be forced on anybody, but if the prospective patient consents, I don’t see the difference between ‘mind’ surgery or any other kind of surgery.” “I’m quite inclined to agree with you Harry. It seems that the consensus is that the soul of man and his mind are inextricably intertwined. But if that is true, then certainly any condition that adversely affects the mind and mood of man should be opposed. Why stop with surgery?” “Maybe they see psychosurgery as the first step to creating a population of zombies.” “Yes. A method of depriving us of our free will. Consider, Harry, if the method were improved. They could take newborn babies, insert a needle sterotactically into the brain. The skull is soft. They wouldn’t even have to operate. Press a button and cauterize a small segment of some pertinent structure and the child from that moment on would be destined to behave calmly and with equanimity. Or the alternative,” Lapius was warming to his subject. “The same needle in another location, and the youngster might grow to be a raving aggressive untamable individual. A nation might be able to make an army of these types. Or zap another part of the brain and the baby might be a romantic, a great lover; or perhaps we could learn to make musicians, geniuses-- shades of Aldous Huxley.” “Well, Simon, now that you’ve allowed your imagination to romp, what position do you take with respect to psychosurgery. Are you for it or against it?” “For it of course. But it must be regulated like any other technique, to avoid misuse. On balance, it represents important progress. Actually, if it is used to liberate a person from fits, or violent behavior, certainly it encourages free will and removes obstacles to the expression of free will by the diseased mind. But we have certainly come a long way. We can change a kidney, change a heart. Someday we may be able to change a lung or even a brain.” “Is that the sum of what you are going to say tonight?” “Yes,” Lapius said with a twinkle, “unless somebody changes my mind.”
Nurse Practitioners Daily Observer November 2, 1973
The Advent of Nurse Practitioners The New Nurses Seem Somewhat More Liberated
“Harry meet Eleanor C. Lambertson, dean of Cornell University’s New York Hospital School of Nursing. Dean, meet Harry.” I shook hands with the handsome Ms. Lambertson. As we were guided by the maitre d’ to our table I nudged S.Q. Lapius. “What’s the matter with you, have you forgotten my last name?” “Shhh,” said Lapius, “don’t be rude.” There is no point in describing the drinks, or the delicate oriental fare served up to us that night, because the purpose of our dining out was so the Lapius could renew an old acquaintance and badger Dean Lambertson about an article she had written for Prism, the socio-economic magazine of the American Medical Association. “Well, Eleanor, you haven’t changed. The last forty years have been kind to you I see.” “Ah, Simon,” she smiled sweetly, “Gallant as always. I remember even as a young man, whenever we went any place together, how you slam doors in my face.” “Tut tut, Eleanor. That’s a canard. I never slammed a door in your face.” Lapius turned to me, “I’ll admit,” he said, “that in my eagerness to escort Eleanor I often pushed through the portals ahead of her and inadvertently allowed the door to swing shut before she had gotten through, but slammed never. That’s a very provocative statement, Eleanor. But, of course, you’ve always been provocative. Now take that article, for instance--.” “You mean on the expanded role of nurses in health care?” “Precisely. Particularly the term ‘health care’. That’s the catch. Once medical care becomes health care, then the services of the physician can be restricted to care of the ill, and nurses will take over the rest of the so-called ‘health care’ and will make the decision as to when the services of a physician are required.” “Of course, dear Simon. Why should so great a man as you squander your talents on minor problems?” Her irony was not lost on Lapius. “Because,” said Lapius tartly, “only by being able to recognize the major medical problems can one distinguish the minor problems. Major illnesses often masquerade as minor illness. Nurses aren’t trained to make that distinction.” “But nurses for the most part man (I hate that word) the coronary care units, and make life saving decisions.” “Of course,” said Lapius, “Nurses do that after they have learned the criteria for heart emergencies that have been established by the medical profession.” “How about the services nurses perform in community health programs, in nursing homes, in chronic disease facilities, where they have to decide when or when not to call a doctor? Surely you physicians aren’t going to spend eight hours a day with the patients. Nurses do that, and gain a special sense of expertise about their patient’s conditions, and they know damn well when to call a doctor. They are really making diagnoses. It would be a simple extra step to prescribe an antibiotic.” Lapius was busy savoring a mouthful of leafy vegetables moistened in a beige sauce. “As a matter of fact, Eleanor, I agree with you. Nurses can function at the lower echelons of medical practice, and do admirably. I suggest that those that would like to do so be trained as family practitioners be given a degree and license that permits them to practice as nurse-physicians under the discipline of the professional medicine.” “Agreed up to the last point, Simon. They will practice as nurse practitioners under the discipline of the nursing association.” “Impossible,” said Lapius. The American Nursing Association has never established the uniform standards of education that the American Medical Association has. Some nurses have never gone to college. Some have had two year courses, others three year courses. Some have baccalaureate degrees, some not. It’s a hodgepodge. How would we know who is doing what. What objection do you have to nurse appropriately trained, practicing under the discipline of medicine. It might help solve the doctor shortage.” “Then they wouldn’t be nurses, they would be doctors.” “So what?” “I’m not here to help preside over the liquidation of the nursing profession.” “Well then, establish some uniformity of educational standards for your nurses. Petition the state legislatures to issue appropriate licenses for nurse practitioners, and then let the nurses assume medical liability for their decisions.” “I’d like that.” “Fine,” said Lapius, peering under the pewter lids for more food, “Soon we’ll have four professional groups vying for patients and responsibilities in the health field. Physicians, osteopaths, nurses, chiropractors, all with equal rights.” “And in the practice of health care you have forgotten a few others; social workers, psychologists, practical nurses, and nurses aides.” “And under whose control will they be, Eleanor?” “Ours of course.” “Then they will all be fundamentally under physician control,” said Lapius, “since traditionally nurses receive their mandate from the medical profession.” “Oh, but that’s where you are wrong, Simon. Nursing is an independent profession. We no longer are the handmaidens of the doctors.” When we left the restaurant Eleanor complemented Lapius. “You’ve learned something over the years, Simon. I see you opened the door and allowed me through first.” “Only so I wouldn’t be tempted, Eleanor--.”
Growing Pains Daily Observer November 9, 1973
FDA Growing Pains and Drug Efficacy
S.Q. Lapius was busy riffing the pages of the Physicians Desk Reference. Every now and then he would stop to scribble a few notes. “Increasing your word power, Simon? Supplementing your therapeutic armamentarium?” “Nonsense. I only use a select number of drugs. This volume obviously contains more medications than any one doctor can assimilate. But they fall into only a few classes, as you know.” “I know, I know. So what are you doing?” “I’m checking a rumor I heard today.” “What rumor is that?” “Someone told me that Antivert, a proprietary drug used for attacks of dizziness, vertigo to you, no longer contains nicotinic acid.” “I could have told you that. It was deleted months ago.” “On what basis?” Lapius asked. “As I understand it, it was deleted because the Food and Drug Administration no longer believes that the nicotinic acid is effective. That is, the FDA concluded that the antihistamine alone is enough.” “That’s interesting,” said Lapius. “With everyone grousing about the high cost of medications, the cost is forced higher now by making the physician write two prescriptions where one formerly would have been enough.” “But suppose the government is correct?” “The combination isn’t harmful. Why not let the marketplace decide the effect.” “You don’t mean that Simon. That isn’t scientific.” “Neither is the FDA scientific. After all, if a doctor prescribes a drug that satisfied the patients and the patients improve, that, over the long haul, is adequate reason to allow the medication to be used. But the FDA has assumed police powers, arbitrarily knocking drugs off the market. Edrisal, Daprisal, medications useful for menstrual cramps, which seemed to help many women, are no longer available.” “Dimethylsulfoxide, otherwise known as DMSO was killed by the FDA before its full potential could be developed. All research in it has virtually stopped. Yet, the last reports on it were that it had diffused anti-inflammatory effects, and could penetrate the skin with ease and possibly act as a vehicle to carry other medications through the skin.” “And I think it also caused eye damage --.” “Nonsense. Suppose it did. Aralen, the anti-malarial, which is helpful in rheumatoid arthritis also causes eye damage. But the doctor must be trained to know the toxic effect of drugs and to prescribe them only when the benefits outweigh the risks. Aralen is not approved in the country for use in rheumatoid arthritis, but the Europeans use it. It is a hell of a lot safer than gold salts which we use in this country. Sulfasuccidine is off the market. That was good for gastrointestinal complaints.” “Sulfasuccidine – goodness, Simon, how far back are you going. That disappeared more than twenty years ago.” “And more’s the pity,” rumpled Lapius. “In addition, the FDA insists that before a new drug can be put on the market, efficacy must be proved. I don’t see how you can prove efficacy in all drugs. What measures can you use to prove the efficacy of tranquilizers? Certainly animals can’t tell you whether or not they feel better, and even if they do, what does that have to do with man? A few snorts make people feel better too. How, in reality, can the efficacy of some drugs be tested other than by allowing the material onto the market and letting the public judge its effects. The public is no dunce.” “I don’t know about that. Look how many patients come in asking for vitamin B12. Yet you and I know that it is only effective in pernicious anemia.” “You may know that, Harry. I’m not so sure. Why should a patient insist on B12 shots and undertake the expense of a weekly schedule if it does them no good.” “Psychological effect, probably.”* “You can’t prove that any more than you can prove that it helps them. After all, it was the combined opinions of patient and practitioner that developed digitalis, quinine, and the rauwolfia medications. Roots and herbs are the forerunners of many of the medicines we use today in a more refined form. Had the FDA been around we never would have been allowed to discover them. I insist that the only function of the FDA is to establish safety standards. “It is the function of the medical schools to train the doctors in safe use of medications. Any other policy will prevent the emergence of new and useful remedies. “Today, due to FDA regulations, it takes about 7 years to bring a new drug to market, much of which period is concerned with attempts to prove efficacy. The pharmaceutical industry is being throttled by unreasonable demands and the number of new drugs has diminished to a trickle.” “But what about the thalidomide story. There is a perfect example of how the FDA saved the country from a calamity. Look how many babies were born with dwarfed limbs and other teratogenic defects because pregnant mothers received Thalidomide.” “That may be true, Harry. But on the other hand, because of the Thalidomide episode, the world has become aware that many other drugs given during pregnancy have teratogenic effects. Hadn’t Thalidomide been tried somewhere, the awareness of the sensitivity of the fetus to drugs given the mother might never have arisen. Now fetal studies are included in all evaluations of new drugs. Thalidomide may have been a blessing in disguise.”** “The fact is, Harry, that physicians use dangerous drugs like digitalis, quinidine, insulin, and countless others, with considerable care. There is no reason why dangerous drugs should be suppressed merely because they are dangerous. The purpose of having a medical profession is to insure that dangerous drugs are properly used so that their beneficial qualities are maximized and the risks minimized. But certainly this can’t be controlled by a committee of non-practitioners. If this remote control of the practice of medicine is allowed to continue, the art and science of medical therapy will be destroyed. Ugh – I’m getting a headache.” I brought Lapius two aspirin with a glass of water. He popped them into his mouth and swilled the water quickly. “Aspirin is a case in point. It knows when you have a headache, it can lower temperature, it might prevent platelet aggregation, it can cause ulceration of the stomach, and incite abnormal bleeding. Do you think for a moment that this drug could ever have survived the specifications laid down by the Food and Drug Administration?” * Subsequent medical literature suggests that Vitamin 12 has some effect on the brain, so perhaps patients claiming it made them feel peppier were way ahead of the profession ** Thalidomide is used as a therapeutic adjunct in certain tropical diseases, considered the drug of choice in Leprosy and now useful in cancer, hepatitis and autoimmune disease.
Speaking of Cancer Daily Observer November 23, 1973 The Importance of Biopsies S.Q. Lapius always enjoyed presiding at joint medical-surgical staff meetings. It gave him a chance to wear his blazer, and to display his red cashmere vest with the gold buttons. (“It helps to rivet attention on the chair” he told me). Fortunately he had to doff his alpine hat with the feather in the cloak room, but nevertheless he resembled the king pea-cock at a bird sanctuary. Today, however, Lapius wore a conservative blue plaid, the squares accentuating the several acres of abdomen that they were forced to cover. As a matter of fact he was annoyed, possibly angry. He called the meeting to order with a tap of the gavel and made a few acerbic remarks. “Today we have to review five cases, three of breast cancer, one of uterine cancer, one of cervical cancer. In each instance there have been extensive metastases. All the patients are dead or dying. But I’ve taken the trouble to review the charts and note that in each case of breast tumor a biopsy was performed, another was performed in the case of cervical cancer, and the woman with the uterine cancer had a diagnostic curettage performed. –“ Before Lapius could enunciate another word he was interrupted from the floor. It was Dr. Ty Cotton, his favorite surgical sparring partner. “May I address the chair?” Cotton asked in a commanding voice. “You may make a few comments, Dr. Cotton. I’m not sure we are prepared for an address.” “I think we can anticipate what you were going to say, Dr. Lapius, having heard you express your sentiments on the subject so often before. In fact it is becoming somewhat boring. The fact is -.” Now it was Lapius’s turn to interrupt. “At the risk of boring you further and for the benefit of newcomers to this conference, I would like to state my position before you continue with your well-prepared extemporaneous remarks….I have been trying to make a point about biopsies. –“
Cotton was up on his feet. “Yes. Dr. Lapius is trying to make the point that we shouldn’t do biopsies in all cases. Just go ahead and do the radical surgery. Preposterous.”
Lapius regained the floor, and with it some momentum. “Had Dr. Cotton not missed so many meetings, and refrained from sleeping through those he did attend, he would have understood me to say that biopsy is obviously necessary to determine whether or not there is a cancer, but that to cut through a malignant lesion does nothing but spread it.” “Now hold on there,” Cotton was on his feet again. “These are breast lesions. Sometimes there is a big mass. If we don’t cut through the mass we have to excise it. This will disfigure the breast. Women don’t like that.” “Better disfigure than take the chance of spreading the lesion.” “There’s no proof that the lesion will be spread by cutting through it.” “Perhaps not,” said Lapius, “But when you cut through cancer you open blood vessels and the cancer cells may drain through these channels to be disseminated to the rest of the body. It puts the tumor beyond immediate control. If you do have to cut through the lesion, then you should be prepared to do radical surgery immediately, not wait three days for the pathology report, as you did in one of these cases.” “Well,” Cotton stammered. “I thought that it was a benign lesion. It fooled me.” “Yes, of course. These things happen sometimes. But I think that definitive surgery should follow immediately any biopsy, and the excision biopsy in which the entire suspicious lesion is removed is preferable to incisions which chance a cut through the tumor. The same thing occurred in the gynecology cases. A week was lost between the initial surgical diagnostic procedures and the ultimate surgery. This, in my view is too long.” “But,” Cotton reiterated, “You can’t find any proof that surgical biopsy spreads cancer.” “It does in experimental animals. I don’t believe there have been any definitive studies in man. It would be a very difficult study to undertake. But in medicine sometimes we should go along with what is reasonable, instead of always waiting for proof.” Wanda Scrape, the only female gynecologist at the institute waved for attention. There was silence as everyone turned towards her. She was almost too pretty to be a doctor. “Dr. Lapius what is the gynecologist to do? After all you can’t expect frozen section diagnosis of endometrial fragments that are removed during curettage. There isn’t enough tissue to take the chance.” “With the modern techniques you could probably get away with it, Dr. Scrape. Certainly if you enter the uterus with a sharp curette and penetrate an invasive cancer with it, the cancer cells will have more of a chance of spreading than if they were left alone. Agreed the diagnostic curettage must be done. There is even instrumentation now that will permit a proper paraffin section for pathologic diagnosis to be turned out in an hour. All hospitals should have such equipment.” Afterward, Cotton came over to Lapius, and said “Why don’t you stop belaboring the point Simon. You are in the minority you know.” “Of course. But if I convince enough people, then I will be in the majority and you will be the minority.”
Ringing for the Nurse Daily Observer November 30, 1973
Shortage of Hospital Beds When the phone rings, S.Q. Lapius was busy typing something and I was stretched out in front of the fireplace reading the Sunday papers. Because he obviously didn’t want to be interrupted, I allowed it to ring. “Harry,” Lapius barked impatiently, “Do something about that infernal noise.” I struggled to my feet and picked up the receiver, listened for a moment and turned to Lapius. “It’s for you.” “Tell them I don’t want to be disturbed.” “He doesn’t want to be disturbed,” I told the telephone. The phone answered me. I turned to Lapius again. “It’s an emergency.” Lapius organized his bulk into an upright position and having overcome its initial inertia was walking for the phone. “Yes, this is Dr. Lapius.” He listened for a while and then hung up muttering a few imprecations. “Come on Harry. We are going to the hospital.” “Which one?” “Point.” He filled me in on the details of the emergency on the taxi ride over. “You know Jersey Lord, the State Commissioner of Health? He was visiting the shore this weekend and developed some indigestion.” “That constitutes an emergency?” “Not exactly. There’s more to it. When he got to the hospital they didn’t have any beds and so they put him in the hall. He is very upset and wants me to get him a room. That’s the emergency.” “Why call you? You are not his doctor. After all, he knows members of the board of trustees at Point.” “Yes but it’s a weekend. They are on their yachts.” By this time we had arrived. I paid the taxi and followed Lapius into the hospital. We found Lord sitting up in bed, his hands tied to the side-rails. “Lapius,” he called. “You don’t know how glad I am to see you. Untie me immediately.” Lapius was unruffled. “Calm yourself, Jersey. They must have tied you for a reason. Harry, run to the nurses station and find out why Mr. Lord has been restrained.” I ran and returned with the news that Lord had been running up and down the hall and the doctors ordered him to be restrained before he hurts himself and sues the hospital. “You see, Jersey,” Lapius explained soothingly, ”They restrained you to protect you from yourself. Why were you running up and down the halls when you were sick? Surely not a rational act.” “I wasn’t just running up and down the halls. I was looking for a room.” “But Jersey, you don’t believe that they would put you in the hall if there were a room available, do you?” “I know damn well there are rooms available,” Jersey said, straining against his bonds to gesticulate. “After all, I am Commissioner of Health. I have all the figures on hospital bed availability. I supervise the Health Care Facilities Planning Act. If there were a bed shortage I would know about it.” “Well you know about it now,” Lapius murmured wryly. “That’s just it. They are doing this to spite me. For revenge. Now untie me.” “Why would they do that?” “Because I refused to allow them to open their new wing. Now untie me.” “Why did you refuse to allow them to open their new wing?” “Because the community doesn’t need more hospital beds. I have the population figures. Now untie me.” “Well, perhaps you are right, Jersey. Let me make some inquiries.” Lapius strode down the hall to the elevators. He returned shortly. “You are in luck, Jersey. There are a number of discharges due tomorrow. Providing too many emergency cases don’t come in tonight, you will have a room.” “Bur if emergency cases come in --?” “Then you will have company in the halls.” “That’s unconscionable. I can’t wait till tomorrow. There are no facilities in the halls. There is no oxygen. Suppose I have an attack during the night?” Jersey Lord wailed. “Tut, tut,” Lapius sympathized, “Nothing like that will happen. But it is ironic to think that there are sixty eight empty beds available in the annex here if only your office would grant permission for their utilization. It’s a shame. The community spent 6 million dollars to create those empty beds.” “Lapius,” Lord implored, “Have me moved to one of those rooms. No one will know. Untie me.” “I couldn’t do that, Jersey old friend. That would be against the law. Anyway you are not seriously ill. They will probably let you go home in a day or two.” “Untie me.” “I’d like to Jersey, but I haven’t the authority to do that. I am not on the staff here. But I am sure if you promise to be good the resident doctor will have the restraints removed.” On the ride back from the hospital I observed that Lapius seemed unduly harsh. “Not at all, my dear boy. I didn’t create his predicament. Anyway, the law is insipid. Why any group shouldn’t be allowed to start a hospital as long as they follow the codes. Let the market place decide if there are enough beds. The efforts to assure adequate health care have created counterproductive statutes that actually create shortages that can only be rectified after months or perhaps years to litigation.” “You could at least have untied his hands,” I said. “Not at all, Harry. Let him be. It will give him time to think.”
Health Periodicals Daily Observer December 7, 1973 Health Periodicals Helpful S.Q. Lapius handed me the list. “Here, Harry. Mail off checks to the following publications. The renewals to my subscribed medical journals.” I perused the column of names and suddenly stopped. Wedged into the list, which included Lancet, the Archives of Internal Medicine, the New England Journal of Medicine, the American Journal of Medicine, I encountered one that surely was misplaced. “Simon, what’s the Reader’s Digest doing here? A spoof, no doubt?” “On the contrary, Harry, I use that to find out what my patients are reading. For months I have observed that patients would ask questions in clusters. One month it would be about liver disease, another about pulmonary function and so forth. Some of the questions were fairly sophisticated. It was all a puzzle till I had a sore tooth.” “You have lost me,” I said. “The tooth ached like the dickens. I was forced to visit my dentist. There was a long wait, which gave me a chance to catch up on six months worth of Reader’s Digest issues, and there I solved the mystery.” “I’m breathless,” I told him. “Well, you see they usually have an article on some medical thing or other. One fellow, what’s his name, Radcliffe or something keeps writing about the different organs of the body. Has a gimmick – writes about the different organs in the first person. I am Joe’s liver, I am Joe’s lung and so forth.” “Has he done one on I am Joe’s ovary yet?” “As a matter of fact, no. But I think he’s running out of organs. Anyway this month the Digest had a real winner. How to Survive a Heart Attack. I was wondering what was going on. All my patients kept asking me about EWS. I couldn’t imagine what they were talking about. But the article clarified the matter.” “So clarify it for me. What is EWS?” “EWS means Early Warning Signs, and refers to early warning signs of an impending heart attack or one that is actually in progress.” “What happens. Does a light go on?” “You are droll tonight, aren’t you Harry? No, but Dr. Glen O. Turner of Springfield, Ohio felt that if patients could recognize the early signs of heart attack they would get to the hospital in time to be protected against the arrhythmias that prove fatal so often during the first hours of the attack. After all if patients can be brought over the hump of the first few days, the outlook is quite good. The heart will heal. But the danger is that the electrical system of the heart is highly sensitized during the early hours of the attack, and fatal in-coordinate heart rhythms can occur.” “Simon,” I interrupted, “You are lecturing me as if I was a high school student. I am a doctor, remember?” “Oh – sorry, Harry I got carried away.” “You should be carried away,” I said to myself. “Actually I have been asked to address the high school students on this subject, and I guess I was practicing a little. I’m pleased to know that I reached you, Harry. But it wouldn’t hurt you to climb off your high horse once in a while and read the lay periodicals. For instance, do you have any idea how many Americans will die of heart attacks this year?” “About 50,000 and one.” I said looking at him malevolently. I had to admit that they were impressive statistics. I was a little abashed that my guess had been so far off. But I knew I wasn’t going to go around reading the Reader’s Digest. Lapius started foraging in the hall closet for his coat. “Where to now?” I asked. “A meeting of the County Chapter of the American Heart Association.” “Donating your heart to some hapless individual?” “No, Harry. They haven’t asked me to do any such thing. But they did ask me to help plan for the Voluntary Screening Examination that they will conduct at the Community College, on 500 individuals chosen because their answers to a questionnaire about health and heart disease suggest that they might fall into a high risk group. The nurses at the hospital are putting a lot of time and effort into this. It is a worthwhile cause. Sort of an EEWS.” “A what?” “An early-early warning system.” “Nonsense. The whole effort is simply a drop in the bucket.” “Perhaps,” said Lapius. “But it does get people thinking about community health and gets them used to working together voluntarily for community causes. They develop an awareness of the facilities available in the community, and hopefully its shortcomings too.” “Well, Simon,” I told him, “You can spend your time being a do-gooder and social-service buff, but I’ve got some studying to do.” Lapius left without another word. I gave him a ten minute head start and shot out the door. He didn’t know it but I was chairman of the meeting he was going to attend. They way he drives a car, I bet I get there before him.
Remember Bicycles? Daily Observer December 14, 1973
S.Q. Lapius’s blimp-like figure was hidden by a white hospital sheet that was tucked under his chin, exposing his head only. The side-rails were up on either side of his bed. He inspected the plastic bracelet on his right wrist carefully, reading his name slowly, and enunciating carefully the name Gelfand. He peered up at me, “Is Gelfand ill?” “No,” I said, “it’s you who are ill. Gelfand is taking care of you.” “Gelfand is a heart doctor. Have I had a heart attack?” He queries, with some degree of concern. “No, you have not had a heart attack. Now take it easy. Don’t be alarmed.” “Harry, I am not alarmed, simply inquisitive. What am I doing in the hospital?” “You are not doing anything of importance. As a matter of fact I brought you here myself.” “Why?” “You probably won’t believe this, Simon, but you fell off your bicycle.” Lapius pondered this for a moment. “Impossible, Harry. The fact is I can’t ride a bicycle.” “That’s precisely the point, Simon. You can’t. As a matter of fact I was trying to teach you how to ride.” “Strange. I don’t remember a thing.” “I shouldn’t expect you would. You had a bad spill. But you had insisted that I teach you to ride so you would have a method of exercise to help you lose weight. I promised. You met me at the front door on a chilly fall morning, decked out in a blazing red sweat suit, hardly the proper attire, I might add. We drive to the park in a taxi and rented a bicycle for you. Do you remember any of this?” Lapius looked blank. “You are pulling my leg, Harry.” “Not at all, Simon. I held the bike for you while you mounted, and gave you a series of small pushes to teach you how to maintain your balance. On one such push you actually went for a hundred feet or so.” “That doesn’t sound too dangerous.” “It wasn’t, but it gave you unwarranted confidence. You demanded that I push you once more and leave you to your own devices. I tried to warn you, but you would have none of it. I didn’t want to argue. So I gave you a push.” “What happened?” “Well, you went along reasonably well for a few hundred feet, but weren’t able to stop at the crest of the hill. The bicycle gathered speed, and you disappeared from sight. There was a resounding crash. When I arrived you and the bike were tangled in a clump of briars. They account for the scratches on your face. You were conscious, but unaware of your surroundings, and asked that I mix you a drink. I got some of the park attendants, and with long poles we disentangled you and the bike from the briars. However, there doesn’t seem to be anything seriously wrong with you except for a concussion and loss of memory. You’ll be out of the hospital in a day or two.” “Where am I now?” “This is the intensive care unit. However, you’ll be moved to a semi-private room this afternoon.” “Don’t rush that Harry. I quite like it here.” I surveyed the ward-like atmosphere, the several nurses hovering around, the cardiac monitoring machines, the complete surveillance, the close quarters. “How can you like it here? You look like a basket case.” “I like it here because I feel safe here, Harry. Look at all the nurses available to keep an eye on me, to help me in a moment if I need it.” “But there’s no privacy.” “But there’s care. When I want privacy I’ll go to a hotel. The purpose of a hospital is care, and the intensive care unit seems to provide it in abundance. No I’m quite content.” Later that afternoon, they moved him, despite his protestations, by wheel chair, to a semi-private room. They moved him during visiting hours, and had a hard time squeezing him into the room because of the visitors that crowded the bedside of the other patient. As a form of protest, Lapius went limp so they had to get two orderlies to transfer him to bed. He didn’t regain either his memory or his usually ebullient spirits till he returned home a day or so later. “I’m glad I had the experience, Harry,” he confided. “It reaffirms my belief that the American public has been conned by the concept of the semi-private room. They really mean semi-public.” “Do you remember anything of what happened?” I asked, trying to change the subject. “I remember trying to stop that infernal bicycle. I pressed my feet on the brakes but nothing happened. The brakes were faulty. You should have checked them first before you allowed me to use the bike.” “But the bicycles today don’t have foot brakes, Simon.” “Where are the brakes, then?” Holy smokes, I had forgotten to tell him that they are attached to the handlebars. He would never forgive me. I changed the subject. “Did you think the overall care in the hospital was adequate?” “Surprisingly, yes. Even the food was good. They served hot food and cold food. The coffee was cold and the ice-cream was hot.” “Simon, you were a pleasanter man before you regained your memory,” I told him.
Way to Improve System Daily Observer December 21, 1973 Should Patients Have Their Medical Records? “Here’s an article by Budd Shenken, Simon. Isn’t he the guy you used to play tennis with; when you used to play, that is.” No answer. I peered over to him. He lay like a porpoise on his recliner, hands folded across his belly, a black cigar poking into the air like a snorkel. He unclasped his hands as a sign that he was alive. “Good ground strokes. What’s he writing about?” “It’s in the New England Journal of Medicine. An article called “Giving the patient his medical record; A Proposal to Improve the System.” Lapius bestirred himself long enough to light the cigar. “I’ve heard of fresh air, a good night’s sleep, a brisk walk all recommended for improving the system, but I don’t see what giving the patient his medical records has to do with that. Budd had a good serve.” “He feels that patients should have access to their medical records.” “Don’t they?” Simon seemed disinterested. “Apparently not. According to Shenken and Warner (NEJM September 29, 1973) in 41 states patients can obtain their medical records only by going to court, in three states only through an attorney, although not necessarily by litigation. Only three states allow the patient direct access to his records.” “But the medical records are accessible to other doctors and hospitals, are they not? Budd was weak on the volley.” “He feels that giving the patient access to his records would improve the medical system, improve the relationship between them and their physician. The medical record would serve them as an educational tool. Patients would look up unfamiliar words, would be in a better position to utilize physicians, and thus participate in their own care.” “Well,” drawled Lapius, “It might save repetition. Buddy always was a little sluggish going back for a lob.” “He says that by giving the patients their records published guides to medical care would soon flourish, and professional consultant services for records ‘translation would abound in response to consumer demand.’” “He says that patients have been forced into dependency on their physicians on faith alone, and have developed paranoid feelings about the medical care system, thus take things into their own hands and consult quacks-.” “Balderdash. People consult quacks because they often can’t face mortal or crippling disease and reach for straws. Even so sophisticated a man as John Gunther went to a food faddist when his son was dying of a brain tumor. Budd had a sloppy forehand, if I remember.” “He goes on to say that availability of records would enable physicians to better judge the performance of their colleagues. Physicians then would have a clear incentive to practice high quality medicine--.” Lapius virtually bolted from the recliner and started waving his arms. “What right does he have to impugn the motives of the physician. To what other professional does a patient go, often sight unseen and unknown, to place his life in his hands. I haven’t noticed a decline of confidence on the part of the public in the competence and dedication of the medical profession. In the distribution of care, yes. In the inability of some to pay for long-term illness, yes. But those are economic problems. They should be rectified. To blame the doctor for mal-distribution of care is like blaming the airlines because one can’t afford a trip to Europe. A physician isn’t an industry. He is a private person working to the best of his ability at his chosen task. Frankly I resent the slurs aimed at the doctors, the intimations that medical care falls short, the insinuation that they over utilize hospital beds, that if properly scrutinized their patient care will improve. “Sure we have faults. But where is the hue and cry when we read that a municipal hospital is pest ridden, or that the kitchen couldn’t pass a health inspection, or that the hospital nursing staff is shorthanded? Certainly if one were to improve the health system it would seem appropriate to start with the hospitals and institutions, where maladministration, or indifference on the part of the trustees can damage more patients in a week than a poor doctor can in his lifetime. Budd didn’t have much twist on his serve, if I remember.” “Shenken says that in the eyes of planners, administrators, and fiscal intermediates, that physician’s autonomy is unchecked, that administrators and policymakers do not have the capacity to evaluate or control the appropriateness of medical care. That they are increasingly turning to ‘comprehensive organizational solutions that call for increased centralized decision making, and an increase in provider aggregations such as Health Maintenance Organizations, foundations for medical care, neighborhood health centers, hospital based practices, Professional Standards Review Organizations, and comprehensive health planning.’ Most of these solutions would deliver more power to the proposers of reform. Shenken’s thrust is that by giving patient’s access to their own records, doctors would have an easier time with quality control, and that administrative power in health matters would be decentralized, and leave more power in the hands of the doctors.” “Nonsense, Harry. When a doctor becomes an administrator, he speaks of provider aggregates. He is no longer a doctor. Only in practice does the M.D. degree confer the title physician. It’s much ado about nothing. Budd has an interesting idea, but had made too much of it. He should have stuck to tennis.” “Simon, you’ve not only castigated Budd’s article, but his forehand, backhand, volley, serve and speed. You must have beaten him every time you played.” “I never beat him,” Lapius sighed morosely.
Medical Costs Daily Observer December 28, 1973
“You are brooding Simon.” I made a statement of fact. His heavy-lidded eyes behind the lenses of his spectacles resembled those of a sad beagle. S.Q. Lapius snorted. “Not brooding, Harry, disconsolate.” “What piques you?” “It says here that the deductible for Medicare is jumping to $84 a year from $72. “You are not there yet. What’s to be sad about?” “I’ll be there shortly, and by that time the initial payments will be nigh over a hundred dollars. It is not only for myself that I shudder, Harry, but for the millions of superannuated Americans who will have to pick up the tab. After all, the older you get the greater the chance that you will become ill, and dependent on medical care.” “But you aren’t even sick. You haven’t a symptom in the world.” “The fates are uncertain, Harry. I might even have a tumor starting inside of me at this very moment. Anyway, it looks as though the government assumed the medical obligations for the elderly without sufficient research, somewhat glibly. After all, there’s no limit to the care a sick person might require. What happens to someone paralyzed, in a nursing home, slowly deteriorating? First they have to go into a hospital for a brief period of time before they even qualify for payments to a skilled nursing home or an extended care unit. This alone distorts the hospital census and puts people in the hospital who really should go directly to a nursing home. Then after there has been collusion on the part of all concerned to lie a little bit about the need for hospitalization, the patient can be moved to a nursing home where his benefits last for only about three months or so. What happens after that?” “They go home to their families.” “But many families can’t provide the special care the patient needs. I see them all the time. They are brought to my offices in wheel chairs, or sometimes by ambulance. Or, believe it or not, Harry, I make house calls. Ah, sickness doth make paupers of us all.” “You are waxing philosophic tonight.” “You must admit that we have a problem, Harry. After all, as a person ages he grows increasingly dependent on those around him, more and more of a burden, unless some lucky illness claims him quickly. The government is already feeling the pinch as evidenced by the jacked up initial deductible. But in addition, the government is misleading about their promise to pay 80 per cent of ensuing medical costs.” “How can they get out of that?” “It’s a simple device, Harry. My patients, for instance, complain that the government refunds them only 64 per cent of the fee they pay me for an office visit. I was puzzled and inquired into it. I called the Medicare representative, and told them that one of their providers wanted to speak to the chief administrator.” “I’m proud of you Simon. You, a mere provider, got through to the chief?” “A false presumption, Harry. I only asked to speak to the chief. I got instead some untitled functionary, who, however low his estate, seemed reasonably knowledgeable. I asked him why my patients only received 64 per cent of the bill they paid me instead of the 80 per cent of the bill that the government promised to refund.” “And what did he say?” I prompted. “He said that they did indeed receive 80 per cent. I told him the $6.40 on a ten-dollar bill was clearly not eighty per cent. ‘Ah,’ he said to me, ‘that’s what the trouble is. Your bill is too high. It should only be $8. You see $6.40 is truly eighty per cent of $8.’” “And what did you say to that?” “Actually, Harry, I was restrained, and didn’t say what I wanted to say. But I asked on what basis he had gratuitously reduced my bill to $8. He told me the $8 was the average doctor’s fee for the neighborhood or geographical area or whatever it is that we practice in. He said that he had data from a survey that showed $8 to be the prevailing fee.” “Well, maybe you should reduce your fee then.” “Sure, and my rent, phone bill, salaries and cost of supplies as well. That would go over with a bang. But seriously, Harry, can you imagine that situation? They decide autocratically that all medical office visits should cost only $8. They don’t ask how long the visit is, or how many patients the doctor sees in a day, be it 20 or 70, or what the condition of the patient is. “I guess if the government budget gets too large the government may decide I should only charge $5 and refund the patients 80 per cent of that, or namely $4. Certainly this is a classic case of administrative chicanery, default on a solemn promise that a government has made to its own citizens.” “What do you suggest?” “Well, at least tell the public the facts. Admit honestly that the Medicare bill is more than the government wants to pay, and lower the percentage return. Don’t create a façade, and pretend that medical fees are what they are not. The other thing they ought to do is to leave to the judgment of the doctor what constitutes catastrophic and compensable illness. If a doctor testifies that a patient should spend the rest of his days in a nursing home, that should be good enough. Or perhaps ask for another opinion from a different doctor. Leave some room in the system for humane consideration. Life and death can’t be run by administrative codes and statutes. Each individual must be treated as a separate case on its merits.” “I must say, Simon, you are very cranky about this matter.” S.Q. Lapius was not soothable. “Our government is committing a breach of faith. I don’t like to see our government behave in an undignified manner. It casts a bad reflection on Americans who are, after all, a dignified people.” “You are taking it all too seriously, Simon.” “Wait till you grow older, Harry.”
Colored Condums: A Preventative Stitch in Time Daily Observer January 11, 1974 S.Q. Lapius had been fidgeting at his work bench for most of the evening. His work kept him from soliloquizing, and I took advantage of the quiet moments to try to assimilate the latest on the endless skein of events that transpire during the immunological response. But it didn’t last long. With a final grunt of victory Lapius turned from his work and held up a small velvet board. “What do you think of this, Harry?” Affixed to the board were five small balloon things in exotic colors. “Lovely,” I said. “A present for your granddaughter?” “I haven’t got a granddaughter, Harry. And if my son-in-law uses these properly, I may never have one.” I looked closely. “You don’t mean---?” Lapius was triumphant. “I certainly do. These are condoms.” “In color?” “Yes. Smuggled in from Japan.” “Why smuggled? You mean imported, of course.” “No. I mean smuggled. We in America, proud country that it is, do not import condoms. Matter of national pride, perhaps. But look at the colors. Aren’t they splendid?” “Most assuredly they are. Do you think color is a selling point for that product?” “It is in Japan.” “What are you going to do with that display? Hang it on the wall? Wouldn’t you rather have a Picasso or a Matisse?” “I’m going to show these to my patients. To the young girls that come in asking for the ‘pill’ or for an intrauterine device.” “The girls can’t use them.” “No, that’s true. But I am going to try to talk them into having their consorts use them.” “Do you think you will succeed?” I asked dubiously. “Of course I will succeed. Because I will combine this display with the pictures of venereal disease that I have collected. You know, those not very pretty pictures of sores and ulcers.” Indeed I know them well. “With those pictures you might scare them away from sex altogether.” “I doubt it. But I might convince them that the condom serves a double purpose. It protects against pregnancy and against disease. It is unquestionably the best device conceived to prevent conceiving.” “That’s not what I heard.” Lapius chuckled. “Of course I had forgotten. Your generation has had no experience with these devices.” “Well---.” “Don’t apologize Harry. We are all products of our own age. But let me fill you in on a few details. It is true that the condom diminishes somewhat the tactile pleasures one might anticipate during sexual contact, but even that drawback has been overcome to a large extent by the sheer of the material used, lubricants, etc. Condoms have never recovered from the observation of Mme. De Sevigne, who claimed that the condom is ‘armor against pleasure and gossamer against infection’. But of course she said that in the 17th century. Technology has improved since then. Actually now the aphorism can be reversed. The device is gossamer for pleasure and armor against infection.” “Can’t there be an accident?” “Of course there can. But they are tailored better now to prevent slippage. And as for effectiveness, there is a quote in the magazine Human Sexuality (July 1973) of a most impressive statistic by Dr. Christopher Tietze, who said that ‘a group of normally fecund couples, copulating 120 times per year and carefully using a good grade of condom on every occasion, would experience an accidental pregnancy rate of 3 per 100 years of exposure.” “You can’t beat that.” “No. The ‘pill’ doesn’t beat that, nor does the intrauterine device. Besides, look at the medical risk incurred by women who use birth control pills. They suffer a ten-fold increase in the risk of a blood clot in a vital organ compared to the normal population, generalized endocrine alterations, possibly psychological changes, an insult to the tissues of womb and cervix. And women wearing the intrauterine device run the risk of low grade infection. I must say I don’t know why women put up with these contraptions. Why they risk the mutilation of their bodies when a condom would do the same job safely. And don’t forget the additional factor of infection. Use of the condom would certainly halt the spread of the epidemic of venereal disease in this country. It certainly is a paradox that the women’s lib movement, that fights against having the male use them as sexual objects and that demands equality in sexual matters are willing to run these high risks to become sexual objects. Real equality would be achieved if they persuaded their escorts to use a rubber.” “You’re old fashioned, Simon,” I said. “Old fashioned? Old fashioned, you say? That reminds me, Harry. Would you like a drink?” “No thanks – make me a Martini.”
Review of Who Daily Observer January 18, 1974
Sen. Graftin Cloakroom entered the house with his cape flowing. He handed me his cane and a high hat with a velvetized surface that shone even in the dim light of the foyer. Lapius had warned me that he was coming to discuss some of the legislative aspects of peer review, so I wasn’t exactly taken by surprise, but I wasn’t quite prepared for his sartorial get up, black string tie and all. I placed his hat and cape in the closet and he gave me a dime. S.Q. Lapius was polite but reserved. “Yes, Senator,” he said, after they had shaken hands, “To what do I owe the honor of this visit?” After Cloakroom had been seated and was coddling a glass of port wine, I lighted the fire. He muttered some pleasantries, hemmed and hawed and then got to the point. “Simon I want you to help us with the peer review thing. You are aware, of course, that your state society is contemplating bringing suit in Federal court to upset the Bennett Amendment that establishes the Professional Standards Review Organizations. This bill will give the government a chance to monitor its Medicare and Medicaid payments, to be sure that the medical profession is giving good value for the dollar spent. I can’t imagine why doctors wouldn’t flock to the standard and help out. It’s their patriotic duty.” “I didn’t catch that, Senator, did you say idiotic duty?” “Patriotic, Lapius, patriotic,” Cloakroom reiterated sounding a bit miffed. “You are an important member of the society, Simon. You could talk to the leadership and try to forestall the wild hairs who are bucking this amendment.” “Yes, I could--.” “Then it’s agreed,” the Senator said smugly. “I knew you would come around. Any sensible man would be in favor of peer review. Not that we don’t trust the doctors, mind you, but anyone that spends money should have available the means to be sure he has gotten his money’s worth, and that includes government.” “Just a moment, Senator, I said I could – but I won’t.” “You mean you are not in favor of peer review?” “On the contrary, I do favor it.” “But you just said --.” “I’m in favor of peer review of the Congress and the executive branch of government, not of doctors.” “Aren’t you being ridiculous, Simon. We are reviewed by the voters every four years, and by the press daily.” “Not good enough for me. You should have someone looking over your shoulder day and night, checking your expense accounts, questioning your appropriations, watching your voting record. If your peer reviewer doesn’t like what he sees he should have the power to kick you out of the Congress.” Cloakroom scrutinized Lapius carefully seeking signs of jest and good humor but found none. Indeed, Lapius was frowning, no mean feat since it meant that he had to do physical work to mobilize his heavy jowls. “Senator,” Lapius said slowly, “I’ve given this matter considerable thought. Wouldn’t you agree that the medical profession has attained a record of remarkable proficiency? That the practice of medicine is extremely effective. We can prevent disease, cure what once were incurable diseases, transplant organs, replace arthritic joints.” “Yes, of course I would agree with that. But you must remember that it was the government that subsidized much of the research that enables you to do these things.” “Of course it did. But the medical profession was alert and disciplined enough to take advantage of new findings and to incorporate them into practice. The cooperation of industry has been important. We have remarkable drugs, electronics, plastic implements to assist us. But the important thing is that all these advances have been brought to the patient.” “That’s the problem, Simon. They haven’t been brought to enough of the people.” “Hell Senator, that’s not our fault. The point is that when the government brings the people to us through Medicare and Medicaid, these patients can get the best medical care available anywhere up to and including coronary bypass surgery, renal dialysis – you name it.” “Of course that’s true.” “Well, damn it, Senator, if you believe that’s true why do you want to monitor us? Do you believe there is some sort of collusion between doctors and patients to fleece the government? Do you believe that just because it’s free someone is going to be willing to spend one day more in a hospital than is necessary, or undergo a kidney transplant, or walk on crutches?” “Of course not.” “Then why look over our shoulders. How can there be too much care? Don’t the poor have as much right to nurse their neuroses as the rich? Haven’t they the privilege of being hypochondriacs if they want? Who are you or any government to say just how much medicine is enough? If a patient feels better for no other reason than that his fears are allayed, or gets moral support and reassurance from a visit to his doctor, are you prepared to say that that is over utilization? Sure some people take advantage. Sure some people are doctor addicts – but then a visit to the doctor is what they need. If they had money they would support the habit. Why deny the privilege to the poor. And keep in mind also Senator, that some people only go to doctors when they are sick. Are you going to legislate what is sickness? Are you going to make laws deciding just how lousy you have to feel before you are entitled to go to a doctor? That is what peer review will lead to.” “So I take it you won’t help me,” the senator said lamely. “Not in peer review for medicine. But, Senator, perhaps you could help me with a project.” “What would that be,” asked the disconsolate solon. “You could help me on the Senate floor, pass a bill that would enable the medical profession to peer review the government.” “You are out of your mind, Lapius,” Cloakroom said sternly. “Perhaps, but hear me out. I’ve always been impressed with your logical mind, senator. You have just agreed with me that the American medicine is efficient, well disciplined and effective. We both agree that the fact that it doesn’t reach everyone is an economic problem not a medical problem. Right?” I had to fill the Senator’s glass with more of the rich port wine before he would nod assent. “Well, then,” continued Lapius. “In contrast, let us consider the record of the government since the end of World War II. Our country has fought 10 years of unremitting warfare in South East Asia. We have allowed our cities to deteriorate. We have lost most of our public transportation and our railroads are shambles. We have subsidized turnpikes and thereby the trucking and automobile industries, and fixed things so that each American uses more energy in a year than the entire nation did during the civil war. Finally we have allowed ourselves to run out of energy reserves, polluted the air, stripped the country side, and lost command of our coal fields. That’s a lousy record, and I haven’t even started to list my complaints. It was certainly a smaller list that caused the revolution against George III. “Yet our government with its record of continuing failure at properly managing our affairs, now has the gall to ask the public to believe that if it were allowed to manage the medical profession, the standards of practice would improve. No no, my dear Senator. It is the other way around. The medical profession has proved itself at its chosen task. “Logic demands, it seems to me, that the government should place itself in the hands of the medical profession. After all, we have a better record of accomplishment than you do.” “Lapius,” Cloakroom said, “If I wasn’t sure you were joking I’d say you lost your mind. Incidentally, can’t you turn up the heat? This place is freezing. The fire in the fireplace can’t warm this room.” “Sorry Senator. We have to conserve heat. Harry, get the senator a hot-water bottle.”
There Is a Difference The Health-Industrial Complex Daily Observer January 25, 1974 I had never seen Lapius so eager to get to a lecture hall, with no promise of late buffet to lure him. The talk, to be held at the Academy, was sponsored by the League for Political Involvement, an organization I had never heard of. “Hurry, Harry,” Lapius croaked hoarsely, “we’ll be late.” He had laryngitis, and for two days there had been a welcome silence as he scribbled notes to me, mainly instructions about food, alcoholic medicinals, and poultices for his neck. Tonight he was draped in a woolen muffler which scarcely suppressed the smell of wintergreen that bathed his neck. We bundled into a taxi and soon were wedged into the narrow theater seats at the Academy. We arrived about five minutes late and the talk was in full progress. I dozed from time to time but Lapius kept poking me, and finally scribbled a note, “Stay awake, damn it. This is important.” I missed a lot of it because the speaker was monotonous, but, in synopsis, it went something like this. “There is a difference between medical care and health care. The former is a system in which a person goes to a doctor because he is ill. The latter system offers comprehensive health care. In the first system the patient seeks care, in the second, care is supposed to be delivered to the patient. Obviously, either system is expensive, and currently there are several plans extant to cover the costs. You all know Blue Cross, Blue Shield. Then there is private insurance underwritten by large carrier, Medicare and title 19, or Medicaid, for the elderly and the poor respectively. –In addition there is the Kaiser Permanente plan which is a non-profit medical corporation that renders service to large blocks of people, such as unions, provides free hospitalization, and is so geared that the incentive for the profit sharing doctor group is to shorten hospital stays so that there will be larger profit to share at the end of the year. In the wings are the Medical Corporation plans of the American Hospital Association, and the Medicredit plan of the American Medical Association. There are also government-funded clinics subsidized through Housing and Urban Development and other governmental agencies are operating in the so-called inner city areas for the very poor. So although private practice and the traditional person to person relationship of a patient to his doctor still exists the trend is definitely towards medical groups and corporate practice. Because of the difficulty that an individual doctor has in negotiating fees with large carriers or governmental agencies, and because many feel that some of these agencies use their financial clout to influence terms of in-hospital medical practice, doctors are forming unions. “Medical practice is in reality becoming a service delivered by power blocks rather than by individuals. I doubt that the government will nationalize medical services until it has a chance to see various plans in action, and test their durability. The nation is too diverse to institute just one or the other plan. For instance, in rural areas, there isn’t sufficient population density to warrant the Kaiser plan, or even perhaps, the medical corporations envisioned by the Hospital Association. –The nation is struggling with the problem of bringing the highest level of medical care to its people. Technology and communication are available for this. In the process the practicing physician, as we know him today, will disappear. His place will be taken by a different sort, one not so averse to fitting into administrative systems, for the doctor of today will not readily suffer himself to be cramped into restrictive molds. But there are many who don’t mind this, and they will become the doctors of tomorrow. –It is difficult to say how this will affect the research thrust of American medicine, but this will also be a function on the level of government research subsidy. “To integrate medical services, large medical centers, for specialized function will emerge and duplication of services will be avoided. Hospital construction will accelerate. The electronics industry will cooperate to provide home monitoring systems, some of which are already in use, so that someone with a pacemaker can dial a number, plug in a jack and be told whether or not to come in for a new battery. The miniature telemetry that has spilled over from the space effort has already made its influence felt, and clever analytical devices and monitoring modules will be on the market. Sophisticated tests that a few years ago could only be performed in large centers will be available for offices, clinics, what have you. The plastics industry enables doctors to look around corners into every crevice of the body with relative ease. “It is canard to say that doctors are unpopular. They are possibly the most popular element in our society, or else why cry all the time for more doctors. Actually, everybody likes the doctor. It’s just their take-home pay that people don’t like, and strong forces are joining hands to restrict it. “In short, we are in the process of forming a health-industrial complex that will dwarf the military-industrial complex that President Eisenhower warned against. Numerous citizens opposed the military-industrial combination because it is easy to be against war. But it will be very difficult on any grounds to oppose the health-industrial complex because what citizen, legislature or congressman will dare cast a vote against health? The doctors, of course, will lose considerable freedom in such a system. But they might not be the only ones. “A collective health system is, by necessity, an administrative system, and administrative systems are harsh, and restrictive of everybody’s freedom. If improperly organized, we could find ourselves one day living under a health czar, or an administrative health establishment where people can be told you must do thus and such because it is good for your health, and the health of your community. A comprehensive health system will have power to regulate ecology energy sources, sewage disposal, and construction. It will have to eliminate slums, rats and infestations to provide for a healthy atmosphere. It will be empowered to order mass vaccination programs---all this power deriving from a central source. “I don’t argue against the concept of a government dedicating itself to the health of its citizens. That’s what governments are for. But in the process of trying to attain this higher level of social organization, beware that those who govern your health have at least the professional credentials to presume to do such a job, and that power is balanced by opposing forces--.” After it was over, Lapius was beaming. “Did you like it, Harry?” “Not really.” Just then the moderator regained the lectern and spoke into the microphone. “I want to thank Mr. Tunney for presenting the lecture on behalf of Dr. Simon Q. Lapius, whose laryngitis---.” “Ooops!”
X-Ray Dept. Packs It In Daily Observer February 1, 1974 “Finished, blotto, they quit.” S.Q. Lapius waved his cigar with an air of finality. “Who quit?” I asked. “The x-ray department over at the hospital. All of them. Gone. The whole kit and kaboodle.” That was precious information and deterred me momentarily from completing the dictation of a case report. “Who is going to do the radiology now?” I asked. “Oh, another doctor has been hired and there will be a reasonable albeit bumpy transition period.” “Exactly what happened? I heard some rumors, but this is certainly a shock.” “That’s the way it is with institutions. In with the new, out with the old,” Lapius said sharply. “The details aren’t very important. Simply that the old radiologist and the board of trustees couldn’t come to contractual terms.” “But these changes take their toll in hospital efficiency,” I remarked. “Astute observation, Harry,” Lapius said, complimenting the obvious. “The fact is that question whether a hospital is entitled to hire physicians to run a department has not been answered at least to my satisfaction.” “Why shouldn’t a hospital be allowed to hire physicians?” “Because a hospital is not licensed to practice medicine. Nor are the members of the Board of Trustees.” “Suppose the Board of Trustees is composed entirely of doctors?” “Even so, they are a board, a legal entity. Legal entities cannot practice medicine.” “Are there alternatives?” “Of course, Harry. Hospital based departments could be concessioned to the physicians. The hospitals should be paid rent. Provision should be made for excess monies to be devoted for research. The hospital should stipulate a rate of expansion, commensurate with community growth. The contract could even stipulate a fixed fee for service for the physicians.” “How would that differ from the usual employment contract where the hospital hires the doctor?” “All the difference in the world,” Lapius said through tight lips, lighting a cigar. “You’ve got one lit already, in the ash tray over there,” I said, pointing. “Oh yes, well put it out like a good fellow. One is all I need. Where was I? Oh yes, all the difference in the world. If the department is set up as a concession the doctors have the right to hire help at the highest salary base, to buy the best equipment regardless of cost, to expand into other techniques. On the employer-employee basis, the hired doctor must go to the administrator for every expenditure. He can’t compete with the market for the best technicians, nor has he a free hand to buy the best equipment. Why should any doctor have to be satisfied to work with the tools provided by a Board of Trustees or a hospital administrator. They really haven’t the sophistication to know the intricacies of the specialty. Too often good practice is impeded by their budgetary scruples.” “But suppose the doctors who set up the concession are pinch-pennies?” “Get rid of them. The hospital would have the right to expect the very best service for the right of concession.” “But who is to judge?” “Details, my boy, mere details. They can easily be worked out.” “But if a hospital can’t practice medicine, then how can they hire interns and residents? Wouldn’t that be the same thing?” “Certainly, Harry. It would. The hospital should turn over the monies to the medical staff to hire interns and residents, as well as emergency room physicians, and be responsible for them and the jobs they do.” “Fine, but suppose the staff doesn’t accept that responsibility?” “Then we would be back to where we started and the hospital would have to practice medicine.” “So why bring it up in the first place?” “Why don’t you go back to dictating your charts?” Lapius said huffily. “You obviously weren’t listening to anything I said.
A Plan of Prevention Daily Observer February 8, 1974 “What do you know about Ameriplan, Harry?” The voice of S.Q. Lapius was confidential. Why did he pick just that moment to interrupt? When my mind was unburdened, and I wasn’t concentrating on anything in particular, Lapius was usually silent. But the moment I became involved, as at this moment, in replaying the chess game in the Daily Times, Lapius was sure to derail my train of thought. It was uncanny. “The Ameriplan?” I said without looking up from the board. “You mean a hotel at which breakfast is included in the price of the room?” “That’s the American plan. Ameriplan is different. Are you interested?” “For days, Simon, you have suggested that if I studied the masters’ games in the papers I might provide better competition for you in chess. I am doing just that. Apparently you don’t want better competition. I will set it aside and listen to you.” “Do so, Harry. This is more important. If it will assuage your feelings I’ll let you win a game or two.” I deliberately plucked each piece from the board and placed them one by one back in the box, then sat back to listen. “Harry, you are being childish. But never mind that. The Ameriplan may affect your future as a physician. One thing is sure. Everybody is coming up with a new plan on how medical care in the United States will be dispensed. The Ameriplan is the American Hospital Association’s entry into the field, put forth in a 91 page booklet which can be obtained if you write to them at 840 Lakeshore Drive, Chicago, Ill. 60611. The Ill., incidentally stands for Illinois, not sickness.” “It sounds fascinating so far,” I offered. “It is. It is a comprehensive plan for the dispensing of what is called health care. It is oriented to the maintenance of personal good health and the prevention of illness in contrast to the present system which is primarily oriented to the treatment of illness after it becomes acute.” “Sounds good,” I said, wondering when I would be able to get back to the chess game. “Well, if not good, interesting. They propose to have federal legislation enacted which would require the adoption of federal regulations defining the scope, standards of quality, and comprehensiveness of health services and stating the benefits to be provided for all of the people. These regulations would be administered at the state level with care being provided locally by the Health Care Corporation. It gets even better as it goes along. Listen. ‘Each Health Care Corporation would synthesize management personnel, and facilities into a corporate structure with the capacity and responsibilities to deliver the five components of comprehensive health care to the community, health maintenance, primary care, specialty care, restorative care, and health related custodial care.’ “‘The proper growth of Health Care Corporations would only occur through the most appropriate economical use of all resources. Enforceable regulatory controls would be established by legislation in each state to assure that needs would be met without unnecessary construction or duplication of services. –All persons in the community would have a role in identifying how health services would be provided – To advance the development of Ameriplan, legislation must be enacted at the federal level. This legislation would set forth the benefits to be provided under the Ameriplan. These regulations would define the scope, standards of quality, and comprehensiveness of health services, and would be administered by State Health Commissions. In turn, the State Health Commissions would approve Health Care Corporations and authorize their operation.’” “Sounds like someone is packaging oranges,” I said laconically. “Funny you should say that, Harry. The group that devised the plan was headed by a grocer. The American Hospital Association offers a plan that provides for nothing less than a blue print for dictatorship.” “But the credo of the United States, the right to life, liberty and the pursuit of happiness, includes I should suppose, health.” “Of course, Harry, but not necessarily at the expense of liberty. Under this plan legislation could be enacted to abolish cigarettes, alcohol, prostitution, and all the other evils that provide a little zing to life. Not that I am for these things, mind you, but I have a feeling that the founding fathers included in their concept of liberty, the privilege of foreshorten one’s life by indulging in harmful pleasures.” “What’s your point, Simon? After all, there’s nothing wrong with creating a system that provides for the health of the people.” “It’s the manner by which it is provided, Harry. After all, Ameriplan is nothing less than a gigantic bureaucracy. It is health administered on a corporate basis. It is the hospital system magnified a million times to include all interpersonal relationships. It will convert medicine into a confrontation between the patient and a machine; between the patient and an administrative code book. Look at the average hospital today. The nurses have been diverted from patient care to satisfying a series of directives that tell how patient care should be performed. Instead of nurses using their common sense to attend a patient’s needs, they must look first to obeying the rule books and completing the records so that inspection teams will be satisfied. But more important, the system calls for one hundred administrators for every doctor. Now I have nothing against administrators. I just don’t like them.” “That’s not personal, of course.” “Not really,” said Lapius blandly. “But since I can do their job and they can’t do mine, I feel the positions should be reversed. They should be working for me.” “That will be the day, Simon.” “I guess you are right, Harry. It seems more appropriate that doctors should be serving people who had a two year course in hospital administration, from a remote college in the valleys of the Teton range, that holds classes in the local church auditorium.” “You don’t have to be sarcastic, Simon,” He continued unabashed. “I’m exasperated by the continuing attack on the medical profession, which although it practices to the highest standards of excellence, is blamed for the inaccessibility of medical service to large masses of people.” “Are you saying that the capitalist system doesn’t work, that free enterprise is dead?” “No, Harry, I am just bemoaning the paradox that the free enterprise system spawned the highest level of medical practice in the world, but that the system will be socialized in order to provide its services to all Americans.” “What alternative do you have?” “Simple, Harry. Give all Americans the money to purchase medical service at predetermined rates, but don’t destroy the uniquely random marketplace system that has provided the incentive between industry, the profession and the community, to produce the most sophisticated level of medical expertise in the world. It would seem a shame, in order to distribute the high level of health care that is currently available, to have to kill the system that produced it.” “In other words, why kill the goose that laid the golden egg?” “Some would put it hat way, Harry.”
But It Worked! --Nerve Pills Daily Observer February 15, 1974 S.Q. Lapius tore the sheet from the typewriter and handed it to me. “Here Harry, a patient interview.” Lapius would do this on occasion, reconstruct encounters he had had during the day that he thought might prove of subsequent interest. I started reading. “May I help you?” “That’s why I’m here.” “What seems to be the trouble?” “I have a pain in my chest. It radiates to my back.” “You seem very nervous.” “Of course I’m nervous. I don’t like doctors.” “How long have you been nervous?” “All my life.” “I guess you were delivered by a doctor.” “I guess so.” “You are fidgeting a lot. Do you always do that?” “Only since my divorce.” “How long have you been divorced?” “Three years.” “Did you get divorced because you were so nervous? I mean did that contribute to the discord in your home?” ] “Possibly. Could we hurry up? My husband is waiting for me.” “The husband you just divorced?” “No, my new husband.” “Well, of course we can.” “My other doctor said the pain was due to pleurisy.” “I am inclined to think that this pain is due to a muscle spasm.” “My other doctor had me in the hospital for three weeks for pleurisy.” “Possibly you had pleurisy then.” “Why would he hospitalize me for muscle spasm.” “I didn’t say he hospitalized you for muscle spasm. I said that the present pain seems to be a muscle spasm.” “But it feels like the same pain.” “What would you like me to do?” “Treat the pain.” “I will treat you for muscle spasm.” “Why don’t you just give me the same pills my other doctor gave me?” “What were they?” “Nerve pills.” “He gave you nerve pills for pleurisy?” “No. But they worked. I think that you ought to treat me the way he treated me. It worked.” “Why don’t you go back to your other doctor? He seems to know the case.” “He is too far away. We moved.” “I will be glad to renew the prescription you have.” “Okay. But why do you disagree with my doctor? He was one of the biggest doctors in town.” “How tall was he?” “About 5’10”.” “I am a bigger doctor than he. I measure over six feet tall.” “I mean he was very smart. Why would he say I have pleurisy if I have a muscle spasm?” “I don’t know why he said that. Would you like me to treat you?” “For what?” “For the pain in your chest.” “Okay. But I want to be treated for pleurisy, not for muscle spasm.” “Well, suppose for a day or so I just treat you with his tranquilizers? Then we will see how you feel.” “But he didn’t give me tranquilizers. He gave me nerve pills.” “Well, nerve pills is another name for tranquilizers.” “But I don’t need tranquilizers. I have pain in my chest.” “I’ll be glad to try to help you but I really don’t know where to begin.” “How is it that you doctors all disagree on the same things all the time? Why can’t I get the same answers for my pain? Why do you doctors all tell me something different?” “I don’t know why doctors say one thing or another to you, my dear. Incidentally, do you have a sample of the nerve pills your doctor gave you?” “Sure I have. Right here in my purse.” “Might I see one of them?” “Sure, here. Hey, what are you doing? They are my nerve pills. You just popped two of them into your mouth.” “Yes I did, didn’t I?”
Educationalists Taking Over the World Daily Observer February 22, 1974 Upon his return from Florida, S.Q. Lapius buried himself in his den, clamped a set of stereo earphones over his head and didn’t talk to me for three days. It had been quite an effort for him to go to Florida in the first place, since it meant that he had to overcome his aversion to flying. The word aversion was a euphemism for “fear”. I had, in the past, flown with Lapius, not in the least a tranquilizing experience. Of course the seats were too small, the space for his feet and knees, to say nothing of his abdomen, too crowded. The seat belt had to be pulled to its maximum stretch to encompass him. And he was wont to observe wryly, “If it’s so damned safe, Harry, why the belts?” He remained subdued and in deep concentration during take-off, permitting no intrusion on his thoughts, which, I was to learn, were concerned only with maneuvering the vast flying machine into the skies. I tried to explain to him that that job was the sole responsibility of the pilot. “Nonsense, Harry. We all must do our share. After all, if the contraption falls to the ground, it isn’t the pilot alone who suffers.” When Lapius finally came out of his morose introversion I was able to ask him what he accomplished in Florida. “Not a thing.” “Were they polite?” “Barely. As you know I was invited to present my views on open enrollment to the annual education convention. But all I met was educationalists.” “Who did you expect at a convention on education?” “Teachers, but they don’t exist anymore. I learned, to my dismay, that there is a profession of educationalists.” “Didn’t you know that?” “No. When I was in school, if a man was a Latin scholar he was deemed qualified to teach Latin. Now you have to be qualified in education, then you can take Latin as a minor course and that enables you to teach it. You can’t teach mathematics just by becoming a mathematician. First you must take education courses.” I was sorry to hear that he had gotten so cold a reception. He had gone to Florida to espouse his plan for open enrollment in professional schools. I knew his talk backwards and forwards, because before he left, he had practiced it ad infinitum, before and after every meal, which took up the entire day except for sleeping hours. His point mainly was that the first year of professional schools should permit open enrollment. This would have the following advantages. It would obviate the necessity for someone applying to the various colleges all over the country, which cost up to $50 per application, thus disadvantaging those without the money. It would save time, because if a person was not admitted he would have to go through the entire process the following year. It would give everyone the chance to embark on the career of his choice, and leave it to the honest competition of a demanding curriculum to determine who would succeed and who would fail. It would tend to recreate educational standards, which lately, seem sorely lacking, and overall, it would be more democratic than the present system. I had tried to point out that his innovation, which wasn’t really so new, because they did that in many countries of Europe, would still graduate the same number of doctors, lawyers, dentists, what have you. “Of course. But you might get a better mix of graduates this way. Look how it is run at present. A student goes to college, then applies to a professional school. An admission committee, never having met the man, judging from grades alone, makes certain cold assessments. Then a certain number are accorded interviews, then the selections made.” “I don’t see how your way is better.” “You don’t?” Lapius’s eyes widened in surprise. “I am surprised at you. I thought that you had learned something through the years of our friendship, Harry.” I ignored the remark, which Lapius accepted as a signal to continue. “After all, how can an admissions committee from a brief interview really make a choice? From the applicant’s record – a cold uninformative document. But in open enrollment the faculty would have an opportunity to observe the student for an entire year. They would be in a position to offer remedial help if need be, or to take into account any number of factors that contribute to the making of a doctor.” “It seems to me,“ I told him, “That would give certain students an opportunity to ingratiate themselves with the faculty. Students with smoother personalities might do better than the more abrasive person. All you would be doing is substituting one set of inequities for another.” “I don’t agree. But even so, the system would be less complicated than the one currently in use. And most important, it would offer real hope – because people would be given opportunity where none exists.” Anyway, it was with that mood of hope that Lapius embarked on his plane to Florida. But I found his black mood on his return irritating. “What are sulking about?” I scolded. “So they didn’t agree with you? Does everyone have to agree with you to make you happy?” “Not at all, Harry,” Lapius said solemnly. “You know better than that. It wasn’t that they agreed or disagreed with me. The problem was that they ignored me.” “How was the flight back?” “That was better. They didn’t ignore me. As a matter of fact, they paid considerable attention to me. The even searched me.”
Lapius---On Med Schools and Grades and Ethnic Admissions Daily Observer March 1, 1974 The mail reminded me of Christmas all over again, an inordinate number of letters, all addressed to S.Q. Lapius. Those with M.D. after his name I arranged in one pile, those with racist or bigot after his name I arranged in another pile. “Throw them in the garbage,” he instructed me. “Don’t you want to read them?” “What for? Their contents have been inscribed on the envelope. I am sure they will not be enlightening.” The latest rash of fan mail was in response to his suggestion that the medical schools were discriminating against topnotch students and denying them admission, replacing them with students of lesser proven caliber in order to strike some sort of social balance. “As a matter of fact,” Lapius said, “there is a case in the courts right now, brought by a prospective law student who claims that he was denied admission to law school because the school felt bound to give his place to a member of a ‘minority’ group, by which is usually meant black or Spanish speaking.” “But if he is an ‘A’ student he will have no trouble getting in elsewhere,” I said. “True. But suppose he is a ‘B’ student, and all the other law schools adopt the same attitude.” “But don’t the medical schools have to strike some sort of ethnic balance? After all, doctors deal with so many different types of people. The nation has to have enough black doctors to deal with blacks---.” Lapius interrupted me sharply, “---and Mexican doctors to deal with Mexicans, and Norwegian doctors to deal with Norwegians, and Gorgonzola doctors to deal with Gorgonzolas. The list is endless. I thought in America we had solved this problem by eliminating all qualifications except that of competence for the making of doctors. Patients want the best doctors they can get. When was the last time a person wanted to know your lineage as a prerequisite for becoming your patient?” I had to admit that was true. Patients went to doctors because they were recommended by other patients who had been helped. “But still, there have to be doctors who will practice in the ghettos and poor areas ---.” “And you automatically assume that a black physician will immerse himself in the ghetto? He might, but then again he might not. He might surprise everybody and become a research scientist or get a job with the National Institute of Health.” “What’s your point?” “My point is that,” Lapius sighed exasperatedly, “the job of the medical schools is not to solve social problems but to train doctors. That if they choose to admit inadequate students just because they are disadvantaged, in the hope that they will, upon graduation, return to their own neighborhoods, then they are foisting on the disadvantaged, inferior doctors. Everybody should have access to the best medical care there is available. The job of the schools is to create a cadre of the best physicians it can. It happens to be the job of the government or community to see to it that this care is available to all. One shouldn’t despoil a great profession in the guise of satisfying a social need.” “But you must admit that until recently a black student had great difficulty getting into medical school?” “But that is changed now.” “But the black community is educationally disadvantaged,” I persisted. “Of course it is. But this won’t be changed by admitting a person to medical school on anything except merit. The poor have always been educationally disadvantaged. In the old days this was corrected by having City Colleges that the poor could go to free, and these colleges had high educational standards. The inferior education of the poor can only be corrected by subsidizing in these neighborhoods, excellent schools with high competitive standards. In the old days, if a student failed, he was forced to run to another career. Today we permit the students to persist with marginal grades. It is foolishness. We have based our educational system on the fact that everyone must initially learn reading and writing and arithmetic. There are many people who are natural mechanics, builders, artists, athletes, musicians, who are indifferent to the three R’s. Look at it this way, Harry. Can you carry a tune?” I shook my head dismally. “Only if it’s in a portable radio,” I said. “Well, suppose you were born into a world where the fundamental communication was musical. How would you fare?” “Miserably.” “Well, that’s my point. Do you feel that in that case, you should be accepted to play for one of the symphony orchestras?” “Sure, if they wanted to ruin the orchestra.” “Well they don’t want to ruin the orchestra. Only the medical profession.” “What would you do to redress the balance, Lapius?” “I would pour millions of dollars into education. Create schools of many disciplines, with different emphasis. I wouldn’t create an immediate hostility to education by forcing everyone into the same initial educational mold. Then, given my way, I would have an open admission to the professional schools, create a competitive curriculum, and graduate only those who met the standards. This way the late bloomers would have a chance to show their stuff. Or those with the driving ambition to come out ahead, might even do better than brighter students who were lackadaisical. That way everyone initially would have a chance at it. The way it is done today students are discouraged in advance. Why it costs so much even to apply to medical school that the poor are immediately disadvantaged.” “But that would be expensive.” “Everything is expensive. It really boils down to just how we want to spend our money. If the government subsidized medical schools, and created an open enrollment for the first year, they could solve a lot of problems. Students who couldn’t cope would have to leave. After all, they are setting up an expensive administrative agency to supervise medical care. The money could be better spent at the educational level.” “How would you have felt if you had been kicked out of medical school?” “Rotten. But not as badly as if I had never been admitted in the first place,” Lapius said, as he started to go through his mail, which meant the conversation was over.
Nobel Prize Oversight Daily Observer March 8, 1974 The Medical Tribune, January 2, 1974 had a full page spread. The headline said “Radioimmunoassay’s Impact on Medicine Revolutionary.” I read it to Lapius. For once he showed an immediate interest. “Read on, Harry,” Lapius commanded. I read on as follows. “The word radioimmunoassay is not defined in medical dictionaries (c. 1968) still on active duty, and has also been skipped by Webster’s Third. Yet, in the nearly two decades since two New York Investigators discovered the principle of radioimmunoassay (RIA) this technique has had tremendous impact on both clinical medicine and basic research. Its uses range from the diagnosis of digitalis intoxication to the screening of unsuspected drug abusers, and the list of applications is expanding. “The late Dr. Soloman A. Berson, together with Rosalyn S. Yalow, PhD., performed the landmark research leading to RIA at the Bronx Veterans Administration Hospital and Mount Sinai School of Medicine. Their personal evaluation of what the technique can accomplish was described succinctly in a lecture they had prepared just before Dr. Berson’s death last year. “’In brief,’ they summed up ‘RIA or other competitive radioassays are likely to be adapted for the measurement of any substance of interest that is difficult to measure by other means.’” Lapius waved his arm at me, a substantive signal to shut up immediately. The great man wanted to speak. I stopped reading, but he only sighed. “That sigh was meant to convey a message, I presume?” I asked. “Yes it was, Harry. The sigh was a lament.” I was somewhat miffed that all that reading had evoked naught but a sigh. “The article doesn’t seem to be sad. What’s to sigh about?” I asked. Lapius ignored the question. “Do you realize, Harry, that the technique of Berson and Yalow enables us to measure substances down to a trillionth of a gram. They have indeed revolutionized medicine. They should receive the Nobel Prize for that work. Up until their investigations we could only surmised at gross hormone interactions. Now they can be proved, measured, and evaluated.” “And that’s what the sigh was about,” Lapius continued. “Solly died last year, alone, while attending a medical meeting at Atlantic City.” “You know him?” “Of course. But the Nobel-Committee has a policy that it has adhered to throughout the years with only one exception, never awarding the prize posthumously.” “Who was the exception?” “There were rumors that Berson was to be nominated but that he stipulated that unless Yalow was included, he would turn it down.” “But who was the exception?” I asked. “It’s not important,” Lapius said impatiently. “However, there is now a possibility that Yalow and Berson as a team will receive the prize, because Yalow is still alive, and can accept it in behalf of Solly.” “Who received the prize posthumously?” “What difference does it make? How well I remember Berson. He reminded me of John Garfield. He crackled and shot sparks like a high voltage line. I knew him before he got into medical school, which was a long time because it took him four years after graduating college to get in. He was rejected by 30 medical schools.” “Simon, never mind that, who was awarded ---?” “Yes 30 medical schools rejected him. I hope he receives the Noble Prize for that alone, so that their inglorious decision can be emblazoned in brass in their hallowed halls. Berson and an entire generation of Bersons were refused entry to medical school because they were Jews. In those days there was a lot of racism in the school system. “There was a saying that Jews were aggressive, Italians lazy, Irish ambitious, and thus, with these undesirable characteristics, shouldn’t be given first choice to medical school.” “Well, that’s a thing of the past now, Simon.” “Not entirely. Now there is a sort of reverse racism. Schools tend to deny admission to deserving students to accept instead marginal students from the ghettos.” “Well, we owe it to them.” “Yes. But not to marginal students. Only to the best. Otherwise the quality of doctors will deteriorate.” “But we need more black doctors.” “Harry. We need more doctors. Period. No man should be denied admittance for his race. No man should be admitted for his race. His credentials alone are what must count. Actually we should probably follow the lead of many European Universities. Admit anyone who wants to be a physician into the first year of medical school, and then graduate those only who have met the educational standard. This would be fair and eliminate all the nonsense with respect to admission committees etc. And there would be less risk of losing a Sol Berson by that practice. Think, Harry. Berson had to struggle for four years with a fearsome singleness of purpose to thwart the system that tried to exclude him from medical school. Yet look what a tremendous contribution he made. No one person, no committee can decide in advance who will be great. The answer, Harry, is open admission to medical school.” “Simon, for goodness sakes. Tell me, who was awarded the Nobel---.” “Dag Hammarskjold.” *
*The Nobel Prize was for RIA was awarded to Roslyn Yalow. Correspondence with the Nobel Committee resulted in a copy of Nobel Foundation Code of Statutes that stated the rule for the award. “Work produced by a person since deceased shall not be considered for an award ---“. However, in this case the prize WAS awarded for the work of someone who had died, but his name was excluded. I expanded on this in the following acddendum: Nobel Catch 22: Genius Forgotten. Printed Daily Obesrver June 30, 1980 The 1977 Nobel Prize for Medicine was awarded to Roslyn S. Yalow for work she did in conjunction with Dr. Soloman Berson in developing the radio-immune-assay techniques which has revolutionized the science and practice of medicine. Briefly, this technique enables laboratories to measure all hormones and other substances in quantities as small as a billionth of a gram (or 1/30 billionth of an ounce, for those not yet converted to the metric system). Until this epochal work of Yalow and Berson, hormones were roughly quantitated by injecting a sample of blood or serum from a patient into a laboratory animal and judging its biologic effect by the crudest of standards, then translating the result into international units. For most hormones biologic endpoints were not available to do even rough assays. Only after the RISA technique evolved did scientists appreciate the minute quantities of the substance that made the endocrine system work. Unfortunately Dr. Berson died in 1971, and therefore he became, according to interpretation of the will of Dr. Nobel, ineligible for the prize. Dr. Yalow in her acceptance speech acknowledged that had Dr. Berson been alive he would have been right there with her in Sweden sharing the prize. In his speech awarding the prize, Professor Rolf Luft of the Karolinska Institute, Stockholm, fully described the work of Berson and Yalow in the opening paragraphs, but towards the end of the dissertation Dr. Berson’s name gradually faded into the background and the award was made to Dr. Yalow. In a fateful way the award does a disservice to history, because in the genesis of the development of RIA it is impossible to separate the contributions of Yalow and Berson. The unique intellectual qualities of each of the doctors dovetailed over a collaborative period of more than 15 years to produce the phenomenal scientific by which medicine thrives today. All publications during this period are either Berson-Yalow or Yalow-Berson. Thus to award the prize only to Dr. Yalow fails to perpetuate the historical truth of the discovery. My interest in this event stems from the fact that I was casually acquainted with Dr. Berson before he entered medical school, and that Dr. Yalow, prior to receiving the Nobel Prize was gracious enough to address the Ocean County Medical Society, so I had a chance to meet this brilliant lady as well. Distressed that Berson’s name is omitted from Nobel archives, I wrote the Nobel Committee to point out that the development of RIA was of such a nature that in the award, the omission of Berson’s name perpetuated a historical distortion. I do not recall having received a satisfactory answer. I thought that perhaps the King of Sweden might be interested in this unique situation, and having had nothing to do one afternoon, dropped him a line. He forwarded my letter to the Nobel Committee where it received prompt attention. The committee stated that it had acted in accordance with the will of Dr. Alfred Nobel, and sent me a copy of that portion which alluded to the Nobel Prize.
I had always understood that no Nobel award could be made to a person who had died, although an exception was of course made in the case of Dr. Dag Hammerskjold, former Secretary General of the United Nations, who received the Nobel Peace Prize after he had been killed in an airplane accident. The Nobel Committee obviously felt that Nobel’s will preclude giving the prize to the deceased Berson. Imagine then my surprise to read that the Code of Statutes for the Nobel Foundation states “Work produced by a person since deceased shall not be considered for an award ---“. And there’s the rub. In awarding the Nobel Prize in
Medicine for 1977, the Nobel Committee did award the prize for the work “of a
person since deceased”, since the scientific contributions of Berson and Yalow
are so intertwined as to be indistinguishable. By awarding the prize to Dr.
Yalow the Nobel Committee was also awarding the Prize for the work of Dr. Berson.
Only it forgot to mention it. It is a unique situation and the Nobel Committee
should acknowledge the fact that the award of the prize to Dr. Yalow is indeed
official recognition of the work of Dr. Berson also. His name should be on the
plaque.
Doctor’s Watch Dog Daily Observer March 15, 1974
It took some doing, and S.Q. Lapius had to introduce himself as a former classmate of Charles C. Edwards, assistant secretary for health of the Department of Health, Education and Welfare, but finally the call was put through, Lapius motioned to me to pick up the extension. “Hello, Charlie. S.Q. Lapius here.” “Who?” “You may not remember me--.” “Of course I do, S.Q. It’s just that I get so many calls. What can I do for you?” “I’m just curious why you are pushing so hard for these Professional Standard Review Organizations, Charlie. After all, you are really putting a watchdog on the doctors. I am not sure they deserve that. But in addition, it may hamper their care of patients. It’s hard to make independent decisions if you have some government agency looking over your shoulder all the time.” “That’s the wrong way to look at it, S.Q. Actually, I believe that the PSRO’s can provide the medical profession with a vehicle for change whereby the best and most effective of care becomes the standard care. We can establish norms that all physicians can adhere to. For instance, if a patient with a heart attack could do just as well with two weeks of hospitalization, instead of three, then the PSRO should be able to shift the pattern of care. No one will be looking over your shoulder.” “You will be looking over my shoulder. Why should a doctor be concerned about what your governmental organization decides should be the national norm. Every case must be decided on its merits.” “But you know as well as I that three weeks of care for a heart attack is too long.” “No, Charlie. I don’t know that. It depends on the case. Sometimes five weeks is too short.” “But look at all the hospital beds we would free for other cases, Lapius.” “If you are short of hospital beds, Charlie, build more. The practice of medicine has a right to change slowly. Doctors have to adjust to new norms at measured pace, not be pushed into new value judgments by a government agency.” “You know, Dr. Lapius,” Edwards was becoming acerbic, “We must consider society as a whole, not just the patient.” “No so, Charlie. We must consider the patient only. He doesn’t come to us to have us consider him in light of other social pressures. He wants to survive that heart attack, and he wants to be in the safest environment possible until he recovers. Sure we may be extravagant with time and hospital beds, but that is what the sick person expects and needs.” “But we can’t take care of all our citizens on that extravagant a basis, doctor. It is not reasonable to expect that.” “Why not? We took care of Europe after the war to the tune of countless billions. We are still sending aid to Vietnam and India and a number of African countries. It would seem to me that the list of priorities should have our citizens on top.” “That’s a political question. We can’t get involved in that. Incidentally, not to change the subject, but we are coming out with a new national health insurance plan, which will afford every American the opportunity to obtain health insurance, and we are offering a broader benefit package than we had previously considered.” “I see,” commented Lapius, “And you won’t build more hospitals, but will insure beds for this increased population of patients by mandating shorter hospital stays, bringing pressure on the doctors to send their patients home earlier. You know, Edwards, not every patient who leaves a hospital goes to a posh home, with proper heating and facilities, or a loving family waiting to render proper nursing care, or the wealth to buy it. Some go home to cold water flats, poorly heated, no insulation, no family. Are these patients going to be discharged early from hospitals?” “But Lapius, the nation has to be careful. As we extend health care to everybody, the cost becomes stupendous. We will have to raise new revenues. We will have to manage the system with great restraint. Otherwise we would have intolerable cost escalation. It is the responsibility of the doctor to monitor costs.” “The hell it is. It is the responsibility of the doctor to take care of his patient. That is all.” “That is where we disagree, Lapius. The fact is that we can’t construct a system that is inherently perfect, not so long as patient care is a matter of judgment. Incidentally, Lapius, I don’t remember you exactly. Were we in the same class?” “No.” “But I thought you told my secretary we were classmates.” “Well, thanks for your time, Dr. Edwards. It was nice talking to you.” Lapius hung up. “There you have it, Harry. You heard him. He is going to take the judgment out of medicine. Next they will remove the compassion, and all the elements that make it a humane profession.” “But you admit there is a problem. To extend medical benefits we will have to expect to pay a big bill.” “Well, that’s preferable to lowering the quality of care. Medicine won’t be improved by the imposition of a medical Czar who will tell each of us what to do and when.” “You never were in the same class as Edwards, were you Simon?” “I would put it another way, Harry. He never was in the same class with me.” (The source for this article was written by Dr. Edwards for Medical Tribune, December 5, 1973)
Credibility the Cure? Daily Observer March 22, 1974 “Here Harry,” S.Q. Lapius commanded as he tossed the magazine into my lap, “read this.” I picked up the magazine and started to read the lines that Lapius had demarcated with a marker. “Well?” Lapius said, impatiently. “Well what?” I answered. “Read the piece.” “I am reading the piece, Simon.” “But you are not reading it out loud,” S.Q. Lapius complained. “But you have already read it.” “Of course, but I want to hear it again.” I read aloud, from the Talk of The Town column of the New Yorker Magazine, December 17, 1973. It was all the more remarkable, because it was only the 14th of December, 1973. But I read aloud anyway, “…Credibility is the modern version of candor. Candor entails truthfulness, but credibility does not. Credibility is the public relations version of truthfulness. It is truth’s ‘image’. And, like any other image, it can be manipulated and faked. Probably none of us should be surprised when politicians offer us credibility instead of the truth. What is odd is that audiences sometimes seem to be satisfied…” “A nice distinction, eh, Harry,” Lapius said, after I had finished. “Very nice,” I agreed. “I always like The New Yorker,” Lapius confided, as if I didn’t know, since he had me read excerpts such as this from the different issues of the magazine almost weekly. “It’s sort of a cerebral decongestant. The New Yorker does to the mind what Dristan does for the nose. Clears away congestion.” I found myself reluctantly forced to agree with Lapius. I enjoyed the distinction drawn between candor and credibility, between the truth and believability. It is what I had been trying to put my finger on for months. The nation and its institutions, for a long time now, from the presidency down, had been floating trial balloons of credibility. Advertising agencies had been creating images of credible products to the extent that we have become used to the appearance of truth in place of truth itself. I mentioned this to Lapius. “Yes, Harry, of course. You understand the point. We have become overly concerned with the representation of truth. I see this in hospitals all the time. Weekly I am called to the medical records library to sign out charts. While doing this I must affix my signature to orders that I neither gave nor sanctioned at the time that a resident on duty ordered a drug for one of my patients. This is because some higher accrediting authority has proclaimed for reasons unknown, that the orders of all resident physicians must be countersigned. This is obvious fraud, sanctioned by the hospital administrator, the board of trustees, the state and federal authorities. “I must also sign all justifications for prolonged utilization of the beds by patients and back date my signature. Again, a fraud, sanctioned by the powers that be.” “The fact is,” Lapius sighed, “that we have become hypnotized by the appearance of records and charts, as if, in fact, they represented reality, and we have been coerced to commit minor perjuries in writing to confirm a demand by authorities that dole our accreditation, or other inspection agencies. Everyone in the hospital conspires to perpetrate this type of deception. The end result is that more money is spent taking care of patient’s charts, than of the patients themselves.” “Have you any suggestions?” “Yes, of course. To thine own self be true. The doctors should stop being accessories to the trickery.” “But when there is the possibility that accreditation will be withheld, that third party will withhold funds.” “Sheer blackmail, isn’t it Harry. We are asked to yield ground on our morality and ethics to satisfy our leaders and bankers. Physicians should decline to become partners to this chicanery.” “But Simon, be reasonable. If we don’t countersign resident physician’s orders, then we will be called at all hours of the night for minor things that the house physician can take care of.” “Wouldn’t it be better to admit the truth of things. That the resident physician is empowered to treat hospitalized patients in an emergency.” “But if you don’t countersign an order, then the physician may be held liable if a patient succumbs, not necessarily because of treatment. Your signature is admission of your responsibility in the case.” “And if I do sign, than I am taking responsibility for an act over which I had no authority. Actually, the system is a fraud. It should admit the truth of things. That on occasion a resident physician will have to take responsibility for patient care. That is the bald fact, and no amount of post dated countersigning alters it. It only alters the appearance of fact.” “In other words, come what may, you opt for candor in place of credibility.” “Precisely.” “Then how come you’ve adjusted our scale so it is shy about three pounds?” “That’s different,” said S.Q. Lapius.
To Blame or Not to Blame Automobiles Daily Observer March 29, 1974 S.Q. Lapius wanted me to teach him how to drive a motorcycle. It was a reasonable request, energy crisis and all that, but what made it a dubious venture was that I had great difficulty once trying to teach him how to balance himself on a bicycle. As a matter of fact his command of the automobile left much to be desired, and I had always assumed that he had gotten his driver’s license by way of some sort of grandfather’s clause pertaining to horse and buggy, because I doubted that he could pass a driver’s test. “That’s just the point, Harry,” Lapius said, countering my unspoken arguments. “My apparent erraticism as a driver is really due to the fact that the American car is an erratic animal.” “Come come, Simon. You aren’t going to blame an unbroken string of traffic tickets, minor accidents and near calamities on the automobile. Surely you must accept some of the blame.” “Surely I will. I accept blame for having bought the car in the first place. But beyond that, the fault is all mechanical.” I admired his intrepid denial of complicity. “You know what they say, Simon, it’s not the nut on the wheel that caused the accidents, but the nut behind the wheel.” It had been a bantering conversation to that point, but apparently I touched a nerve. “Nut behind the wheel indeed,” he exclaimed. “There are 50,000 deaths and 500,000 injuries annually on American highways. This, despite magnificent four lane turnpikes with median barriers and plenty of room for passing. But as soon as a road is engineered large enough to permit two cars to pass safely, Detroit builds a wider car. Americans didn’t start to buy foreign cars because they were cheaper. That was a factor, of course, but they actually were more roadable, as a result, safer. Recently in Europe I had occasion to drive a foreign car over winding mountain roads. The compact auto, with positive steering and a feel for the road took me through safely, despite the unfamiliar and treacherous terrain. A behemoth of an American car on the same roads would have been suicide to drive. Let’s look at some of the facts. First, the steering. The average American car, for reasons that defy comprehension, has too much play in the steering wheel before the front wheels begin to turn. You have to guess your way into a curve, jiggling the wheel to find the exact degree of rotation. The rack and pinion steering of foreign cars turns the wheels into a direct ratio to the steering wheel. This is a help. “Secondly, the American car is softly sprung. The manufacturers cater to the soft ride. They brag that you can’t feel the bumps. Well you can’t feel the road either. You are riding an animal that has faster reflexes than you have, which has the power to purr up to a hundred miles per hour, and the driver has no idea how fast he is really going unless he peeks at the speedometer, which is usually hidden by one of the spokes of the steering wheel. In a foreign car you can gauge your speed by the feel of the road. “In addition, the American car tends to wander. You can’t take your eyes off the road for a moment. Otherwise you may find yourself brushing the fellow in the next lane. Drive a European car and you will see the difference. The car maintains its courses. Furthermore, because of the soft springing, the body of the American car leans away from the chassis on turns. This tends to pull the weight of the car to the outside wheels and threatens to overturn it. “Only in the last year or two have disk brakes become standard on some of our cars, while they have been installed on European cars for years. No, Harry, you can’t convince me that it is the nut behind the wheel. It is the nut behind the drawing board that is to blame.” “Consider, if you will, your posture in an American car. Forget that. Consider trying to get into an American car. It requires training in Yoga. And once inside you are only one step away from the lotus position.” Lapius was just getting up a full head of steam. “After all, Harry, I am not a tall man by American standards, yet I can’t find a domestic auto in which I can sit without my head rubbing against the roof. As a matter of fact I was developing cradle-cap, which is why I first switched to foreign cars. Even in the Volkswagen I can sit upright.” “Boy, you sure are turned on to this subject, Simon,” I said trying to placate him. “I sure am. We both see the accident cases coming in to the emergency room. Half a million people crippled each year, many maimed for life. I claim it is because of inadequate brakes, the inaccurate steering, the momentum of a poorly sprung body, the excessive power all of which add up to poor readability. These figures must be reduced. Do you realize that in too many cases the lucky victims of auto accidents are the dead. If we could reduce the number of accidents we would go a long way towards relieving the pressure on our emergency rooms, hospitals, convalescent centers. And one way would be to build safer cars, engineered more sanely than they are today.” “And you are gong to improve this all by learning to drive a motorcycle?” I asked innocently. “Harry, you’ll see. I’ll let you be my first passenger as soon as I master the device.” “You know, Simon, for the first time I am glad we are running out of gas.”
Nixon Calling the Play Daily Observer April 19, 1974 “Here’s an interesting thesis,” Lapius said, folding the paper longitudinally, and peering at the editorial page. “What is an interesting thesis?” I asked S.Q. Lapius, peering over his shoulder and trying to read the small print. “This fellow says that President Nixon merely epitomizes the average American. That his problems merely represent some cumulative total of what we all are guilty of. Namely sharp practices, conniving, contempt for our fellow citizens, and adherence to the adage that anything short of murder goes as long as it helps us get ahead.” “Surely that seems a bit extreme,” I said. “Murder should be included too.” “You know, Harry, remarks such as that are not very constructive, are they?” “Maybe not, Simon, but I don’t like being lumped together with President Nixon. I have nothing against him personally, mind you. As a matter of fact, I even won a few bucks on him on the last election. But I see no advantage at this stage of becoming what might be his sole supporter. After all, why should ordinary citizens like you and I be implicated in an orgy of national guilt because Nixon has problems?” “No Harry. I think that this fellow has something. Sure Nixon has problems. You remember when he was just starting out they used to ask, ‘would you buy a used car from Nixon?’ But the fact is, that if the used care salesman is dishonest as a breed why do we tolerate and make jokes about it.” “Actually we have sort of accepted the sharp practice and chicanery as the American way for too long. We sympathize with people who cheat on their income tax, and take pride in the loopholes, pad our expense accounts. We don’t do this directly. Actually our accountants do it reflexly. But we certainly don’t discourage them.” “Simon what are you saying? That the whole country is one big collective crook? That’s silly. As a matter of fact I just heard the president say he wasn’t a crook.” Lapius smiled. “Maybe you are right, Harry. It’s just that I’ve always thought of America in terms of hard, honest, competitive ethic, and of course that’s how I’d like her to be. As a matter of fact, until yesterday I was willing to accept that proposition that in the main that’s what America was.” “What happened yesterday?” “A football game.” “And that changed your mind? What happened in the football game? Did they hand out too many penalties?” “No. Actually it seems a minor point but I think it important.” “You think what important?” I was interested now in the football game. I didn’t know who had played or who had won, but I suddenly became intrigued with this great game that changed Lapius’s mind about the character of America. “You know the rule about coaches not being allowed to call plays from the sidelines?” Lapius asked owlishly. “Of course. Instead they send in players to the huddle with the plays they want run.” “But this year this is a new wrinkle. The player with the play is just a messenger. He hands the play to the quarterback, turns around and scampers off the field. He doesn’t even have to play.” “I know that Lapius,” I said impatiently, “But what changed you mind about America?” “That did it. The messenger.” “Why, for goodness sake? That’s ridiculous. I don’t follow you.” “Look at it this way. Harry. Why can’t the coach call plays from the sidelines?” “Because he’s not allowed to.” “But why isn’t he allowed to?” “I don’t know. I never thought about it.” “That’s one trouble with America right there. Too many people not thinking about it. Anyway, the reason that coaches weren’t allowed to call plays was because years back the athletic societies thought that it would be nice to have football no more than a test between the two teams of college kids. Not a test of the brains of the coaches. So they made a rule that the coach couldn’t sit on the sidelines and waggle his score-card to signal plays to the quarterback. So the coaches got around this by sending players in to play, shuttling guards, who brought the plays in, stayed for one play, and then gave way to the other guard with the next play. This was really a fraud, but the referees couldn’t stop it because there was no rule against substitution. But this year, the player bringing in the play doesn’t even have to play one single play. He is strictly a messenger. So in actuality, the coach is signaling from the sidelines. By allowing the coach to send in a messenger, the league has institutionalized a procedure that flouts its own original rule, that the coach shouldn’t call the plays. So although he still isn’t allowed to call the plays, he is allowed to send in a messenger to talk to the team. I think that this is the kind of thing America has been doing. It has been hiding behind the rule book, finding loopholes, then changing the rule book ever so slightly to accommodate the new infraction. Finally the original meaning of the rule is lost. After all, isn’t it true that when the motormen in New York decide to go on strike, they threaten the city that they will follow the rule-book to the letter?” “Don’t you think it is silly to prevent the coach from calling plays?” “Sure,” Lapius said, “That’s a dumb rule to begin with. But instead of getting rid of the rule, they paper it over with new rules. Well it doesn’t really matter,” Lapius continued, “I don’t like football that much anyway.”
Controlling Sex Daily Observer April 26, 1974 I always looked forward to a visit by Felix Gautier, because when he was excited fireworks shot from his eyes and the tips of his waxed moustache vibrated so quickly that they virtually sparkled. Gautier was usually excited, but tonight in addition to his agitation there seemed a triumphant air. “Lapius,” he asked, “Have you read the papers?” “Of course I read the papers. Come, Gautier, upstairs to the chess room.” “Chess we can play later. There are more important things to discuss than gambits.” “Felix,” Lapius said kindly, “I don’t invite you over to listen to your vapid chatter. I invite you to play chess, because that is what you do best.” “But Simon, take a few minutes to celebrate. Women are finished, gone. And medical science has done it. I salute you Simon.” Lapius turned to me. “Harry, what the deuce is he talking about?” Gautier overheard. “Simon, Simon. Didn’t you read that they have found a way of separating sperm with only Y chromosomes, the male sperm, from those with X and Y chromosomes, that will produce females as well as males?” “As a matter of fact, I hadn’t heard that. Tell me about it.” “It’s very simple, Simon. A.M. Roberts, of Guys Hospital, London discovered that the X chromosome contains slightly more DNA (Deoxyribonucleic Acid) than the Y chromosome. Thus the sperm carrying the X chromosome is heavier than the sperm carrying the Y or male chromosome. Lapius looked at him blankly. “Really Gautier, does it matter? After all, the chess boards are set up.” “Aha,” Gautier said to me triumphantly, “The great Lapius doesn’t understand the significance of that little piece of information. Do you Simon?” “I am afraid that I do not really care about it, Gautier.” “Are you going to filibuster me or permit me to continue?” Gautier asked indignantly. “After all, I am a guest in your home.” “Continue, Gautier,” Lapius said resignedly, leaning back and closing his eyes. “The point is, Harry,” Gautier continued, turning his attention to me, ignoring the sleeping Lapius, “The point is that the lighter male sperm can swim faster than the heavier sperm carrying the X or female chromosome. Don’t you see what that means?” I shook my head dumbly. “It means,” continued Gautier, “that scientists at Schering in Germany were able to develop a viscous solution that would inhibit the ‘female’ sperm from swimming through it, while the male sperm had an easier time of it. Thus, at the other end of the solution there were more YY male sperms than YX sperms that could produce females. Do you realize what this means? We can populate the world with men. Think what this will do to women’s lib. The collective female ego will be destroyed. For the first time we have the potential to eliminate the race of women from the earth.” “It is sure more refined than leaving baby girls out on the rocks to die, like they used to do,” I agreed. “We will produce men only,” Gautier exulted. Lapius opened his eyes a crack. “From whom?” he asked dryly. “Don’t worry, we’ll find a way.” Lapius sat up. “The trouble with you Gautier, is that you always sell science short. After all, one of the first rules is that for every force there is an equal and opposite force. While the Germans were creating statistically higher yields of male sperm, here in America a group at Sloan-Kettering were able to use a natural antibody against male sperm that female mice developed, and were thus able to reduce the population of male sperm considerably.” “What good would that do, Lapius? Do we need more women?” Gautier was partially supporting two ex-wives, which accounted for his bitterness. “Well, we could have more cows and less bull, or more chickens and less crowing, more sows and fewer pigs, the male chauvinist kind, that is.” “Bah, Lapius, science is dabbling in frivolous things.” “Obviously.” “I came over to play chess, Simon. Let’s go upstairs.”
Home Care Program Would Cut Costs Daily Observer May 3, 1974 Usually the bell rang when someone wanted to gain entrance, but this time there was a sharp rap on the door. I opened it warily and just escaped a tap on the noggin as Dr. Ernest Crabgrass pushed the door open and entered, brandishing his cane. “Why hello, Dr. Crabgrass, this is a surprise,” I said. “Where’s Lapius?” he asked without bothering to acknowledge my greeting. “One moment please, I’ll find out,” I left Crabgrass who still caressed his cane like a shillelagh, and marched to the living room. “Crabgrass in the foyer,” I told Lapius. “I don’t want to see him.” “What should I tell him?” “Tell him I have the mumps and difficulty walking.” I turned to transmit the message and ran right into Crabgrass, still waving his cane. “Don’t worry, Simon. I’ve already had the mumps.” Lapius gave Crabgrass a warm welcoming smile and threw his arm around the still frocked shoulder of the uninvited guest. “Goodness, Ernest, it has been a long time. Welcome, welcome. What brings you to this neck of the woods?” “I want you to sign this petition, Simon. I won’t take ‘no’ for an answer.” “And what petition is that? The one to abolish Medicare?” “Exactly. Here.” Crabgrass laid a smudged paper on the table and handed Lapius a pen. Lapius took it, leaned over, read the petition carefully and then marked a big X in the appropriate space. “There you are Crabgrass. I’ve signed it.” “An X won’t do, Simon.” “You don’t think I will put my real name on that ridiculous document, do you Crabgrass?” “Why not?” “First, because I don’t believe in the petition, and secondly, because Congress is not going to repeal Medicare.” “They should. They have no right to interfere into medical affairs.” “Well, I would agree with that. But they do have the right to pay medical bills if they want.” “But by paying medical bills they earn the right to dictate to the medical profession. That interferes with our professional freedom and I for one am against it.” “Come now, Crabgrass. Surely you must understand that we can’t go back to the old days where old or elderly people were relegated to the back rooms of their children’s homes. They certainly couldn’t afford protracted illness. Surely we can’t allow the nest-egg for retirement of an elderly couple to be wiped out by illness. That isn’t the American reward for industry and diligence and prudence over the years.” “Perhaps not, but surely it isn’t the American purpose to preserve the nest-egg by dumping these people in nursing homes. Have you seen any of these lately? Even the best offer little more than anonymity and ignominy. Some of those people would be much better off dying at home amongst their loved ones.” “That’s a point, Ernest,” Lapius agreed. “Maybe you should rewrite your petition. Instead of trying to wipe out Medicare, request that it includes a home care program.” “What is a home care program?” Crabgrass asked. “More of your socialist mumbo jumbo?” “Hardly, Crabgrass. It would be a program that would permit the elderly to be taken care of at home. After all, the average convalescent home costs a minimum of $5,000 per year per resident or patient. For the same money most of these people could be adequately taken care of at home by the family in conjunction with a home health aid.” “My goodness, Simon, that would be open season for larceny. The government couldn’t trust families to receive a $5,000 subsidy to take care of a sick father. They might blow it at the race track.” “Sure,” Lapius agreed. “Some might. But then, some might not. Certainly a family would seem a more dependable receptacle for subsidy for the care of one of their own, than the impersonal management of a distant nursing home, in which personnel is always changing. After all, Crabgrass, there are situations which are reasonably self-governing, and it seems to me that family care at home for a sick person is one of these.” “How would it work? I mean, how would the government know who is sick and deserving and who isn’t?” “All the government would need would be the testimony of the family doctor, and-or the affidavit of a social work agency to affirm the need.” “Ha ha, Simon, you are opening the floodgates. People could fake that and steal the government blind.” “Some might, but it would still be a hell of a lot cheaper for the government to trust its citizens, than to distrust them and set up a whole supervisory administration whose only job is to see that the government isn’t cheated by its citizens. It would be more dignified too. Actually by setting up utilization committees and Professional Standards Review Organizations, the government castigates the medical profession, and impugns the honesty of the doctors. I personally resent it.” Crabgrass was becoming impatient. He seized the moment. “Ah, Lapius. So we agree. Medicare must go. Sign the petition.” Lapius sighed. “Poor Crabgrass,” he said patronizingly, “You didn’t understand a word I said. It is you who must go, not Medicare. Harry, show Dr. Crabgrass to the door.”
Medical Leadership Lacking Daily Observer May 10, 1974 S.Q. Lapius was snorting like a porpoise. “Why are you snorting like a porpoise?” I asked him. “That is a snort of indignation, Harry. Here, read this letter I’ve just written to the editor of the Philadelphia Bulletin. That should explain all.” He handed me a rough copy. Dear Editor: Your editorial, Unsnarling Blue Cross (Sunday Bulletin, December 16, 1973), asks for intervention in the Blue Cross-Hospital negotiation, by a Mr. McNerney (National President of the American Hospital Association) and calls them respected “medical leaders”. A medical leader, by definition, is called doctor, abbreviated Dr. Mr. McNerney and Mr. McMahon may be leaders in the economics of medicine, or in the distribution of what is now called health care, or in the nebulous entity formalized now in the medical school curricula as community medicine, or the politics of the new health-industrial complex, but none of this qualifies them for the application “medical leader”. As a matter of fact, there is no medical leadership. The AMA, rent as under by internal strife and defection from its ranks, has adopted a low profile after its invidious role in the debates preceding Medicare legislation. Practicing physicians, singly, and in groups, are being steamrollered in the hospitals by the so-called medical leadership, which consists of non-medical boards, trustees and administrators. Hospital costs are spiraling upwards because of this inept, statutory and strangling leadership. For example, hospital architecture is inefficiently stylized by the promise of medicare and third party insurers to pay for semi-private accommodations. (Semi-private is a misnomer, actually the rooms are semi-public.) But from a medical point of view, the semi-private room has been a major cause of high hospital costs. First, by stipulating no more than two beds to a room, hospitals are forced to sprawl over large tracts, instead of logical compression that wards would offer. Patients are invisible to nurses who have to traverse miles of corridors to get their chores done. Cleaning and heating bills are increased inordinately. Patient care is inefficient, and must be supplemented by electronic surveillance devices. For efficient care, hospitals have returned to the ward concept in creating coronary and intensive care units. They do not even separate men and women in these ‘wards’. In most there may not be toilet accommodations. But the care is intensive, life-saving, and in general, excellent, since patients are under constant surveillance by a group of nurses stationed only a few feet away from the beds. Of course the term ‘ward’ is opprobrious, bringing to mind as it does, the sloth of Philadelphia General, also run by so-called medical leaders, who happen to be non-medical trustees. But a clever architect could design a much more efficient hospital plan that would offer adequate privacy within the confines of a ‘ward’ concept. Of course, we would drop the word ‘ward’ altogether in exchange for ‘care’ unit which might be more palatable to the public. But our medical ‘leaders’ could employ public relations experts to so disarm the public. At present, the doctrine of semi-private accommodations has been so institutionalized that no board would dare submit a new design for fear of being turned down by the various authorities that govern hospital funding and construction. I recall when I worked at a large Geriatric Center, pleading with administration to buy 10 (about $1,000 worth) of soft mattresses to protect patients from development of bedsores. It takes about six months of daily medical and nursing labor to heal a deep bedsore in the elderly. The administration couldn’t find the money which would have saved them hundreds of hours of nursing and medical care and laundering bills, a return of investment of about 1,000 per cent. They hemmed and hawed and finally agreed to try some lease-purchase finagling with third parties, then shuffled the one or two soft mattresses around like chess men, from patient to patient, and of course some went without. I called the administrator of a large, neighboring hospital and suggested that he might save his hospital untold funds by a similar purchase, since bedsores in the elderly are a way of death. He listened politely and said he would get back to me. It is three years now and I still haven’t heard. In neither case was this suggestion brought to the attention of the respective boards of directors. This calamitous inertia is the direct result of the fact that the administrators and trustees are not medical leaders, that they treat institutions instead of patients and that, indeed, medical leadership is non-existent. Only when doctors are given a proper voice and hearing in these institutions, and given that privilege, exercise their righteous indignation at some of the improprieties foist on their patients in these institutions, will there be medical leadership in the health field. Sincerely yours, S.Q. Lapius, M.D. (signed) “What do you think, Harry?” Lapius asked after I had turned the last page. “I figure it will cost about 10 cents to send,” I told him. “Yes, that’s about what I thought it would cost,” Lapius said.
Objection: A Not So Gay Definition Daily Observer
S.Q. Lapius threw the newspaper aside impatiently. “What ridiculous twaddle!” he exclaimed. “Something catch your eye, Simon, pique your ire?” “Obviously, Harry. The American Psychiatric Association has just agreed that homosexuality is not a psychiatric disturbance, but is henceforth to be known as a sexual disorientation disorder.” “You find that annoying?” “No. Disingenuous, would be a better description. After all, a rose by any other name….” “You think homosexuality is a disease?” “It seems to be perverse,” Lapius countered. “But do you believe it a disease?” I pressed him. “Probably. But what difference does it make whether it is called a disorder or a disease. Why must a housewife be a homemaker? Why must a garbage man be a sanitary engineer? Why is a physician now a professional provider? Makes him sound like a pimp, doesn’t it, Harry?” “Well, if you put it that way….” “Well, I am putting it that way. Why the play on words and names?” “To enhance the dignity of the role,“ I said trying to assume a neutral stance. “You talk as if you had a bias towards homosexuals, Simon.” “Well, I do have one prejudice, I must admit.” “What could that be, Simon? Till now I thought you were 100 percent objective.” “Almost. Let us say 99 percent. My abiding prejudice is against their use of the term ‘gay’. Here is a perfectly delightful word, that heretofore could be used to conjure up all sorts of delightful images; viz, merry, blithe, jocund, jovial, jolly, playful, frolicsome, sportive. But now that the word ‘gay’ has been applied to describe homosexuality, we have lost it as an expression of joi de vivre. Even if you talk about a gay child, the parents will deal you malevolent looks. A gay blade evokes images of a homosexual skater. See what I mean, Harry?” “Let’s go back to the beginning. Is homosexuality a disease or disorder?” “What difference does it make which it is. The important issue is that it is an unnatural condition. Heterosexuality is natural to the order of things. The instinctual sexual response is to scent. Female animals in heat put forth an odor that rouses sexual instincts in the male. Without these stimuli and responses, there would be no animal life on earth today. Thus, an attraction of a male for a male, or female for another female runs counter to the natural order of things.” “But if a person is destined to have aberrant instincts, ought he or she be censured?” “Of course not. But they should be treated. Research into the cause of the problem should continue. But if we play semantic games with the problem, and reduce the dysfunction from a disease to a disorder, or, as some claim, to normal variation, then research will stop, and people stricken with the problem will not seek treatment. If doctors suddenly decided that cancer were a disorder rather than a disease that it is the natural destiny of man to die of cancer, then there would be no purpose in trying to cure it, would there?” “But many great people were and are homosexuals.” I said, trying to play the devil’s advocate. “Of course, Harry. In addition, many great poets were drug addicts, De Maupassant had syphilis, Caesar was epileptic, Chatterton and Galois were suicidal, Lord Keynes a pederast, and Joan of Arc a delusional visionary. But because these people were great doesn’t imply that we must adopt their habits, disturbances and diseases. A healthy society can tolerate a certain percentage of abnormal citizens, but if abnormality becomes the rule, society will disintegrate.” “You still haven’t answered my question, Simon. Is homosexuality a disease?” “The important thing is that it be a treatable condition. Once this is kept in mind, it doesn’t matter whether it is called a disease or disorder or disturbance. But if changing the name changes the nature of the problem, so that those afflicted fail to seek treatment, then semantics has dealt society a foul blow indeed. There is scientific proof now, that hormones affect the perception of sexuality; that sexual drives can be altered by giving either men or women hormones of the opposite sex; that animals deprived of their hormone secreting sex organs lose their interest in sex; that a close endocrine link between the brain and the sex organs has been proved to exist. Certainly homosexuals must suffer some alteration in the physiological network.” “To deny that homosexuality is abnormal is to consign future generations of potential homosexuals to a role that if nothing else, is unnatural and uncomfortable. Thomas Mann felt that sexuality was the result of an overwhelming force that overcame a person’s natural inhibitions to intimate contact. Certainly in homosexuality, this force would seem to be misdirected.” I decided to deal Lapius a cruel blow. “How come you never married, Simon?” He peered at me obliquely. “To avoid the possibility of siring someone like you, Harry.” Touche.
Squeeze on Nursing Homes Daily Observer May 31, 1974 Simon Quentin Lapius was preparing for bed, not an ordinary ritual. First he located the sherry to be sure there would be enough for him at bedside, to sip until its soporific effects induced slumber. Next, the porcelain potty he recently bought and stowed under the bed, “to avoid the long cold dark walk to the bathroom at 3 a.m., Harry,” he informed me. Finally, and this was new, a pair of hot water bottles, filled to the brim with what looked like pure steam as it came from the faucet. “What’s the trouble, Simon? Backache? Ear ache?” “Not in the least, Harry. Just a simple bed warmer. You have heard, no doubt, that we must turn our thermostats down to freezing temperatures at hour of sleep. A suggestion from the president. I must admit being somewhat taken aback by the fuel shortage. You know Harry,” he lowered his voice so as not to be overheard in the empty apartment, “the average family governs its life and plans its future with more care and wisdom than our government does. And the very same government wants to tell us how to run medical affairs. It should be the other way around. After all, the medical profession has a long history of success.” I didn’t want to get started on that monologue because it was so late, so I changed the subject. “And the hot water bottles will keep you warm through the night?” “Harry, they are an absolute delight. Beneath a heavy quilt they will retain warmth till morning. They are warm and soft. I think they could replace bundling.” “Why two?” “One is for my feet,” he said, as if that answered the question. “Besides, my joints have been aching lately, and I am preparing techniques to take me into my dotage. I would much rather be self-sufficient at home than ensconced in one of those convalescent centers.” “You are not that old.” “No, but I am getting there.” “What have you against convalescent centers?” “Nothing really, except for the food, the care, and the expense.” “Come on, Simon, you know they are not that bad. We have many patients at convalescent centers.” “True, but things may get worse. The government is now asking doctors to justify visits to Medicaid patients if more than one visit a month is made, and the insurers and Medicare administrators are following suit. This has the effect of cutting back on a service that should actually be increasing. After all, there is no end to the care that one can give to the elderly. As a matter of fact, with increasing age there is increasing dependency, and increasing need for medical, nursing, dietary and physiotherapy services. When finally bedridden, patients must be watched carefully as not to develop bedsores. Yet the government won’t pay for soft mattresses. Have you noticed that the diets are more scanty? That in part is because there is no cost of living adjustment for the nursing homes when food prices suddenly rise. I certainly don’t want to be subjected to those indignities. I don’t want the government, or any other agency, deciding how much care I need. That is what my doctor should decide. No sirree, I want to die in my own bed.” “If you keep gulping that shooting sherry, the chances are good that you will. Anyway, the government doesn’t say that a patient can’t have all the medical care s/he wants, it just says that it won’t pay for all of it.” “But of course that’s unfair. After all, when Medicare was instituted, the stage was set for people to live longer, and the implication was that the tab for the catastrophe of prolonged illness in the elderly would be picked up by the government. Now they are finding out just how expensive good care really is, and are pulling back.” “Well, it is expensive, Simon. As you said, there’s no limit to how much one can do to make another person comfortable.” “Society will set a limit. As a matter of fact, with the moral fences that guarded the sanctity of life, utterly destroyed in the abortion debate, euthanasia will be next on the agenda.” “Do you think it will really come to that?” “It did in Nazi Germany.” “Whoa, Simon. Come off it. That’s not fair. We can’t compare our society to Nazi Germany.” I was getting annoyed. I suspect Lapius was a little tipsy. “We will become more like them the more we compromise our ethical barriers concerning the sanctity of life. As ethical barriers fall, what once seemed extreme, becomes commonplace. It certainly seems paradoxical that the same factions that urge the abolition of capital punishment because they want to protect society from taking a life, urge abortion and the consideration of euthanasia.” Lapius wasn’t tipsy at all. Although he looked ridiculous in his nightgown, nightcap and clutching the hot water bottles. But he was deadly serious. “To what do you ascribe this paradox, Simon?” I asked. “To the God-is-dead syndrome.” “But you were never a religious man.” “True, but I always felt comfortable in the thought that most of us were obeying the law of a higher authority. Without a higher authority everyman must be his own judge, and I am not sure we all have that much wisdom.” “Certainly you don’t want to stay stuck in a rut. After all, if nothing changes, there will be no progress. You are not against progress, are you?” “No. But I would surely like to know what progress is. Everybody defends their concept of progress. Good night. I’m going to bed.” “That’s progress,” I said under my breath.
Relaxing From the Symptoms Daily Observer June 7, 1974 S.Q. Lapius always maintained a discreet silence when I sprinkled the food grains into the tropical fish tank on the theory that since he didn’t enjoy being disturbed while eating, the fish harbored the same prejudice. The fish were a new addition to the ménage. A substitute for color television. When Lapius had successfully parried my arguments in favor of color TV, I was reduced to the contention that it would add some color to the room. “If it is only color that you want I have a better solution, and much quieter too.” Lapius said, and the following day an aquarium resplendent with iridescent fish, appeared. “Of course you will have to take care of them and clean the tank since it is you who wanted them,” Lapius informed me. It was useless to remind him that I didn’t want the fish in the first place. The fish hypnotized him and he would stand for hours watching them undulate in the water. As soon as I had finished feeding them he took his position in front of the tank. “See if you can get me a news program,” I suggested. “After a hard day in the office this is just the type of silent relaxation that I need.” Lapius murmured. “What is so hard about a day in the office?” I asked. He spoke with his back towards me, his eyes glued to the aquarium. “Oh, it’s something I run into every winter, Harry. The patients grill me. They want to know the cause of their troubles. Why does my arm hurt, what is the cause of bursitis, do you think the headaches could be nerves, which food caused me to belch?” “But, of course, you patiently explain these matters, don’t you?” “Bah, Harry. Explanations in medicine are impossible, because each answer brings up new questions. You know that.” Lapius tapped on the glass and watched the fish prance. “At least,” he said, “in the old days when they were testing atomic bombs, I never got questions like that.” “What have atomic bombs to do with it?” “Everything, Harry. Then, when patients came to the office with a complaint, they would say, ‘I guess it’s due to atomic radiation, eh, doctor?’ I would nod wisely without saying anything. Patients like to have a cause for their suffering. Not a deep scientific cause, but something they can relate to their day-to-day affairs. You have those patients, don’t you Harry?” I nodded wisely, but Lapius had his back towards me. “I thought you did Harry,” Lapius continued. “Don’t you have those nervous women who can’t take any medications?” “You mean when every medication you give causes a symptom?” “Precisely, Harry. These people are neurotic, with a storehouse full of symptoms; nausea, diarrhea, tingling of the toes, headache, blurred vision. Every time you prescribe something they pull one of these symptoms from their repertoire and the next time you see them they tell you the medicine made their eyes burn or their hands go numb.” “What happens when they are not on medication?” “Oh then it’s different. Their hands burn and their eyes go numb.” Lapius chuckled suddenly. “I recently was called to attend a man in shock from a sudden heart attack. He was cyanotic, his pulse was racing at 150 beats per minute. He was gasping for breath. He was close to death. His wife came over to me and said ‘I told him not to eat that fish.’” I laughed. “Sure Simon. I recognize that breed. We all have those patients. But why are you so suddenly afflicted with them?” “Not suddenly, Harry. But it always gets worse after the summer.” “What’s so special about summer?” “Oh, during the summer they have air-conditioning. Whatever they come to the office with, they blame on the air-conditioning. The lame shoulder – ‘Doc, don’t you think it was because I was laying near the air-conditioner?’ Or the diarrhea, ‘I knew I shouldn’t have kept the air-conditioner in the bedroom.’ The air-conditioner offers an immediate cause for all summer complaints. But in the winter they can’t figure out why they get sick, and keep asking me all these confounded questions. After all, Harry, we really don’t know the reason for a lot of things, do we? We don’t know what causes migraine, nor can we really explain epilepsy, etc. etc.” Lapius was still staring at the fish. “Honestly, Simon,” I said, “wouldn’t we be better off with a color TV? At least once in a while it would say something. Occasionally there is even a football game.” “Absolutely not, Harry,” Lapius said emphatically. “Color TV makes my eyes water, and usually gives me a headache.”
The Good Death Daily Observer June 14, 1974 S.Q. Lapius stomped into the house caring half the slush of the city with him. He shucked his galoshes in the foyer, hung his dripping coat and hat over the rack and minced into the kitchen, to emerge eventually with a cup of tea. He set the cup on the end table near his recliner and returned to the kitchen, this time emerging with a jar of honey from which he ladled two teaspoons of the rich goo into his cup, persuaded somehow, that it would not add to his ample girth. “The honey dissolves, Harry,” he said, in anticipation of my comment, and as if his explanation explained anything. “I take it the Ames girl died,” I said. I didn’t have to be told, since it was only after an emotionally exhausting day that Lapius replenished his drained feelings with tea and honey. “Yes. Not only did she die, but I was interrogated by the administrator as to the cause of her death.” “But it was leukemia, wasn’t it?” “Of course it was. But at the end she was anemic and hemorrhaging, and losing vision in her left eye and very frightened, so I gave her some morphine. The nurse on the case refused to give it. Said it would kill the girl and she wouldn’t be party to euthanasia, and when I gave the injection, she reported me to the administrator.” “Will anything come of it?” “Possibly. They will probably bring the case up at the quarterly meeting.” “Well, you didn’t commit euthanasia, and even if you did, it’s becoming the vogue now. You read about it all the time, like you used to read articles about the propriety of abortion before that became legal.” “Of course, Harry,” Lapius said, sipping gingerly at the steaming tea. “In the strictest sense I did commit euthanasia. I tried to assuage the pain and fears of the little girl so that she could die comfortably. That’s all that euthanasia meant originally, as defined by Karl Marx, not the communist, but the doctor of the same name who lived 50 years earlier. Euthanasia means the good death. Only in the last half century or so has the word been interpreted to mean mercy killing.” “But in fact, Lapius, didn’t the morphine hasten her death?” “Who knows, Harry? I gave her a dose that would not kill a normal girl. But possibly the dose would hasten the death of a child as sick as she.” “I guess there’s a fine line between ‘good death’ and ‘mercy killing’. Do you think they should legalize euthanasia, Simon?” “No I don’t think they should legalize euthanasia. I didn’t think they should legalize abortion. I don’t think that society can sanction the taking of a life and still remain intact.” “But don’t you occasionally put someone out of their misery, by either an act of commission or omission?” “Possibly.” “Don’t be coy, Simon. You know you do. We all do.” Lapius nursed the tea thoughtfully. He was reluctant to get drawn into this controversy. Finally he looked up. “To be frank, Harry, if I were forced to make a choice between abortion and euthanasia, I would choose euthanasia. After all, the being that is aborted is fresh, with the potential energy for a full and productive life locked up in its genes. The sick elderly person has already spent his treasure of life’s vital forces. Even if his life is saved, he can’t be reconstructed. The best we can do is to return him to some stage of useless chronic disability. Now I am against all forms of killing, mind you, but given a choice, society would be better off choosing euthanasia over abortion.” “But society will have its way, Simon. They will, you know, have both abortion and euthanasia before too long.” “I am afraid you are right, Harry. But it is a grievous error.” “But you admit Simon, that sometimes a doctor does give a drug or withhold an antibiotic to hasten death.” “Of course we do.” “Well, how can you admit that and still be against it.” “I am against institutionalizing it. I am against including permission to kill in the statutes. I am against having the right to life or death put into the hands of some administrative group who will make decisions from a distance. An individual can do certain deeds in the privacy of his conscience that society can’t afford to do.” “But if you do it as an individual it is still murder.” “Yes Harry. It is still murder, if you will. The individual will have to take the risk of being appropriately punished by his Gods, his conscience or his peers. But once society agrees to take a life there is no countervailing force. A nation can’t permit itself to sanction the taking of life for good cause, because it soon may make laws permitting the taking of life for frivolous causes, or no cause at all.” Lapius stopped talking suddenly. I looked over at him. Tears were rolling down his check.
Physicians Must Respect Life Daily Observer June 21, 1974 Simon Quentin Lapius nibbled tentatively on the endive. “I know of no dressing that quite conquers the bitterness of endive,” he said. “Anyway Harry, with respect to your question so vulgarly stated, ‘Where’s it at with medicine?’ Am I supposed to answer that between mouthfuls of salad? It’s rather broad you know. But I think it starts with a reverence for life. Lord C.P. Snow returned to that theme recently. I quote: ‘I believe that we have to act as if each individual life was significant.’ “You remember of course that driving force in the life of Schweitzer was ‘reverence for life.’ All the turmoil of his feelings during the war and at the start of his self imposed exile were finally crystallized in the phrase ‘reverence for life’, without which no physician can function.” I remember reading about Snow’s statements at a recent dedication of the new 188 bed wing of St. Barnabas Hospital for Chronic Diseases in New York. “Snow expanded on this theme. He said that: ‘In many conditions, most of all in those when one is face to face with mortality, there is no substitute for one good doctor.’ “Snow went on to say that a doctor with empathy can do more for a patient than anything medicine can do. Of course there are those who would argue with this. But there is no substitute for empathy, sympathy, a small degree of identification with the feeling of one patient. Snow felt this couldn’t be taught, and I would agree. But Snow felt that a literary thread should be introduced to the medical education.” “How do you feel about that, Dr. Lapius?” He finished his morsel of salad and poked at a drop of oil that slithered down his chin. This gave him time to think. “I don’t quite agree. I think that qualities such as empathy and feeling for fellow man cannot be taught, but somehow result from personal experience, which include personal loss, the pain of aging, disease, anxiety. In other words, experience. Show me a doctor who has been a patient and I will show you a kind and friendly doctor who will be concerned with his patient as a person.” “You think that is most important?” “No.” Lapius had become distracted by a slightly overdone chopped sirloin, and was appraising it carefully before tasting it. “What do you mean no? After the long speech about empathy.” “No! First he has got to know what the heck he is doing. He must be a trained doctor. There is no substitute for that. We can’t turn incompetent nurse-maids loose on the public. But if after a doctor has achieved his competence, if he develops some motherly instincts, all the better. He must rage to protect the health, dignity, and comfort of his patients, but must also be able to inflict painful procedures if necessary. He must achieve a sense of balance so that the risks he imposes on his patients balance the risk of no treatment at all. It’s judgment my boy. C.P. Snow had to live a lifetime to come to his value judgments. Each of us in areas of serious responsibility must reach maturity by the same painful process. It can be indicated as a goal, but it can’t be taught. Pass the rolls please.” He chewed for a moment, then suddenly blurted out an angry stream of indecipherable syllables each surrounded by specks of food. “What was that you said?” I asked. “I didn’t catch all of it.” He dabbed at his chin carefully, then swallowed the bolus of food. “I said, Harry, that Snow would like to introduce mere art into the medical curriculum, but there’s scarcely enough time for the science, to say nothing of literature, music, philosophy and the like. And now there’s talk of doing away with the premedical college years, and shortening the medical curriculum. Phooey.” “That wasn’t what you said, when you talking with your mouth full. Come on, Simon. Out with it.” “I said the last thing we need in medicine is a Snow job.” He looked sheepish, because he hated to be caught in a bad pun.
Pros & Cons of Socialized Medicine Daily Observer June 28, 1974 S.Q. Lapius said “no” for the last time, and punctuated the finality of his mood, by slamming down the phone. I was busy stirring the fire and getting the new log positioned, and really hadn’t followed the conversation that Lapius had just terminated so vigorously. I might have asked him what that was all about, but it turned out to be unnecessary. Lapius sidled over to watch me work, and said, “You will never guess what that was all about.” “Tell me who you were talking to and I’ll take a shot at it.” “Ok. I was talking to Crabgrass.” “He wanted you to sign another petition to have the Congress repeal Medicare,” I said, searching for the wildest improbability. Lapius stared wide-eyed, “How did you know that?” he asked. “Did you know Crabgrass was going to call me?” “No. But I know Crabgrass. He ran the hammer and sickle up on his flagpole the day Medicare was passed.” “Yes,” agreed Lapius. “It figures. One of the most advanced minds of the middle ages.” “But you do agree that government interference does have a stifling effect on the medical profession, don’t you, Simon?” “Of course I do. But that doesn’t mean they should scrap programs that help pay for medical care. It is the way that they do it that should be changed. After all, we physicians gladly accepted government subsidies to research, hospitals, training of doctors, and medical schools. We can’t complain about those programs. They have given tremendous impetus to the entire medical profession. The medical profession, in effect, has accepted areas of socialization.” “Are you in favor of socialized medicine?” “I am in favor of the government picking up the bill for health care, and against any program that disrupts the doctor-patient relationship.” “Terrific. You favor two irreconcilable positions. In the first place, the bill for health is open-ended. There is no limit to how much a government can spend for the health of its people.” “True. But what else are governments for, or at least our government, anyway, but to insure its citizen’s life, liberty and the pursuit of happiness. Certainly it follows that to assure these qualities, our government must invest in health, education, and housing, and create the healthiest environment possible for its citizens. After all, that is what a family does, that is what a community tries to do. The federal government is simply a higher plane of social organization that should be helpful in these matters.” “Then why shouldn’t you favor socialized medicine?” “Because I don’t think it will be necessarily helpful.” “Why not? You are being inconsistent.” “Because it may destroy the medical profession in the process, and without the medical profession, the noble aims cannot be fulfilled. The first generation of socialization seems to work fairly well because the doctors who have been in private practice are swept into it and apply the principles of service they had applied in their private practice. But eventually a different type of person goes into medicine, one who is willing to sacrifice some individuality, to make medicine a routine 9 to 5 job. Personal interest is lost, and as a result the patients suffer. Medical care becomes mechanical. The profession tends to become debased over the years. Treatment becomes administered by codes and statute instead of remaining individualized.” “How can the doctor-patient relationship be preserved if government is going to institutionalize medicine?” Lapius shook his head. “I don’t really know. Perhaps the best compromise would be an extension of the Medicaid system. Set a realistic fee for services, and have the doctor submit the bill for services on a monthly basis as he does today. This will allow patients free choice of doctors, and permit the physician to govern the medical problems of patients, choose appropriate specialists and so forth.” “It could be expensive.”
“Everything is expensive. But they could save
money by eliminating the very expensive watchdog bureaucracy that monitors fees
and services and utilization.” “Be realistic, Simon. No government is going to spend money without finding out where it goes and how it is being spent.” “They did with Lockheed and the Penn Central. To make the system work the government will have to trust the doctors more than it does and to trust the hospitals. Sure there will be some cheating. But the loss to cheating will not be as expensive as the cost of supervising every iota of medical care. If you think your patient needs something you will be able to order it, without the concern that some clerk miles away may deem it unnecessary and interfere with the care of your patient by canceling the order. The systems must be built on faith and trust, and this is where the government has erred. They have set up a policing system which, frankly, in my opinion, runs counter to the spirit of the constitution, and the precepts on which the nation was founded. After all, volunteerism is as American as apple pie. Communities can be depended on to develop volunteer police and fire departments. Volunteer rescue squads sprout all over the place and do a terrific job. The spirit of volunteerism must be built into any government system to make it work, and this is being excluded.” “You favor volunteerism, I take it.” “Of course,” said Lapius. “So why do I always have to build the fire?” “You volunteered, my boy. You volunteered.” Lapius said, warming his hands over the curling yellow flames. “I volunteered?” “I recall you saying “It’s chilly. Why don’t we have a fire.”
‘ATouchy Problem of Definition’ Daily Observer July 5, 1974 S.Q. Lapius was never to be disturbed during the chorale of Beethoven’s ninth symphony, so I waited patiently. As the last chord was struck I turned off the record player and showed him the front page of the newspaper. The headline that had caught my eye concerned the indictment of Boston physicians for manslaughter, because they had performed an experiment on the fetus extracted during a therapeutic abortion. Lapius scanned the page quickly and chuckled, “What the deuce are you so happy about?” I asked. “That isn’t funny. It has fantastic implications. Those doctors could go to jail. They have already been suspended from the hospital. They were performing a research project on antibiotics on the fetuses of therapeutic abortions. Otherwise the fetuses would have been sent to the morgue, the information on the rate of passage of certain antibiotics through the placenta wasted.” “Oh that,” Lapius said, still chuckling, “I saw that. But that wasn’t what I was laughing at. It was the adjacent headline. That aggression was finally defined at the United Nations after 24 years of debate.” “Don’t you think it should be defined?” I asked, a bit miffed that he had contrived to divert the conversation to an irrelevant subject. “Probably not, Harry. Anything that takes 24 years to define is probably indefinable. A definition of aggression figures in the text of the Congress of Vienna held in 1815, and nibbled at during the Hague peace conference in 1907. So it really has taken 150 years to come to a definitive conclusion concerning aggression.” “Well, I was talking about the doctors, and indictments and abortions, not aggression,” I said sulkily. “So was I, Harry, so was I. Anti-abortionists believe that removing a fetus from its mother is aggression; and particularly in this case when the fetus was 24 weeks old and had a remote chance of making it on its own.” “But if doctors aren’t permitted to perform experiments on these fetuses, research in this field, any field, may come to a stand-still. After all, the abortion was legal, and why waste the fetus?” Lapius waved impatiently. “I’d rather listen to the Beethoven chorale again than have you prattling about this nonsense. These arguments aren’t new. Science has always forged ahead in the face of impediments based on moral considerations, theological law, legalisms and so forth. The early great anatomists were grave robbers, and paid for the bodies. Who knows how many murders were committed to sell an anatomical specimen to a scientist?” “What has that got to do with the United Nations finally consummating a definition of aggression?” “The point I was going to make, was that our generation has assumed a fearful burden by trying to define things like aggression, or questions such as what is life, and when does life begin. Not all qualities of life can be rigidly defined.” “Well how do you develop guidelines, then?” “I don’t know,” Lapius said. That was the last thing I expected. For Lapius to admit defeat so readily was confounding. “Do you think that science should stop? After all, if they keep indicting researchers, or placing them in jeopardy, science will slow to a crawl.” “Maybe it will simply be deinstitutionalized,” Lapius answered thoughtfully. “The problem is that we have learned from science that some things are subject to definition. We can define a chemical reaction or a mathematical problem. But what we have not learned, is that we cannot define the philosophical problems of the humanities quite as easily. Nor, perhaps, is it necessary. We know for certain that a 12 week old fetus is not viable outside the body of the mother. We do not know for certain that a 24 week old fetus is not viable. Perhaps therefore the doctors should take cognizance of the fact that abortion is opprobrious to some people and cater to their sensitivities by confining their projects to fetuses in the 12 week range.” “This work was done on a government grant. In a sense the government should be a defendant in the case. They approved it.” “The government might well have to share the blame. The Supreme Court may also bear moral responsibility. Certainly this court action pinpoints the matter. At what point is abortion murder? You know, Harry, for several millennia western society has decided it wiser to leave questions such as the definition of life and death to the law of God. The fact that it took the United Nations 24 years to define aggression makes me think that our forbears weren’t so stupid after all. The problem with trying to define everything is that the definition institutionalizes the subject. It perhaps prevents unreasonable people from doing unreasonable things, but it also deprives others the freedom to make reasonable decisions in the light of their own moral code, public opinion, theology, legality and whatnot.”
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