Laufer’s Rules with Comments

Igor Laufer (1944-2010) was a distinguished, renowned and beloved gastrointestinal radiologist at the University of Pennsylvania, largely responsible for the development and refinement of double-contrast barium studies of the GI tract.

Igor and I first met in the early 1980’s at a conference devoted to inflammatory bowel diseases where I was chairing a multispecialty (e.g., surgeons, gastroenterologists, radiologists, a pathologist) panel and he was one of the speakers. Just before the session began I introduced myself to the various speakers, most of whom I did not know since they came from other institutions and were not in my specialty of pathology. Almost as soon as we sat at our designated places on the stage, me in the center and Igor to the far right, I noticed the eyes of the audience members, almost in synchrony, looking at me and then to the right, at me and then to the right, at me and then to the right … It was much like watching the crowd at Wimbledon following the ball in a fast-paced tennis match. Soon after we started, my fellow panelists also noticed the audience and they also started looking to me and to the speaker to the right. After the session was over, Igor and I realized we were almost twins: almost exactly the same height and weight, the same coloring, the same cut beard and mustache, the same degree of balding, he a little bit more than I. At that time we even had similar frames for our glasses.

Although someone took a photograph of us together in those long-gone days of film, I am unable to locate it. The photos you see were taken in recent years; Igor is at the beginning of this post and I am below. When we originally met we looked even more alike. We spoke a few times in the months after that first conference and confirmed that neither of our mothers could possibly have had the other son; Igor was five years younger and had been born in Czechoslovakia in 1944. I was born in Brooklyn in 1939. He and his mother hid from the occupying Nazis, eventually escaping to Toronto where he attended college and medical school. A year or two after that panel discussion we met again when he came to give a lecture to those interested in gastrointestinal diseases at the Mount Sinai Medical Center, New York, where I was a faculty member. He had a busy schedule and we only had the chance to renew our friendship during a coffee break. Sadly, Igor died in 2010 after a long struggle with cancer.

Why this renewed interest in Igor Laufer? Although I’ve often recalled and spoken about our meeting, the memory is even fresher now that I am working on my second novel (“A Shooting in a Shower”) in which the fact that two unrelated people look almost alike is an important element of the story; memories of Igor have flooded back.

On-line obituaries testify to his great devotion to his family, to his profession, to students and to the art of teaching. They also uniformly recall his wisdom and great personal warmth. In one, Marc S. Levine, M.D., Laufer’s student, colleague and friend, recounts Laufer’s 13 rules to enable others to “benefit from the perspicacity and insights of this remarkable man” (http://appliedradiology.com/articles/laufers-rules).” Although I had not previously known Laufer’s rules, some of which seem conceived at least partly for humor, they immediately looked familiar and deserving of repetition. They are not presented in any particular order, following Dr. Levine’s article, with a few comments of my own.

1. Barium is not a democracy. Barium is the radio-opaque contrast medium Laufer used to visualize changes in the bowel. As example, when a defect is seen in the solid white image of a barium-filled esophagus or colon, it is indicative of a lesion, which can then be biopsied or resected. As I understand it, Laufer was saying that the diagnostic image speaks for itself, regardless of opinion, conjecture or, worst of all, speculation. For him it was the widely sought “gold standard” for examining parts of the GI tract. In Pathology, for more than a century, the hematoxylin-eosin (H&E) stain for microscopy has been and, to a great degree, still is, the morphologic “golden standard” for establishing a diagnosis, widely accepted as superseding other diagnostic. Although newer pathology studies, including immunostains and molecular studies, are now regarded as definitive, as many experienced pathologists know well, in the highly difficult cases where there may be confusing results from one of these more sophisticated tests, the diagnosis can sometimes be found by restudying the H&E. Aligned with Laufer’s logic, Pathology diagnosis is similarly not a democracy. Diagnosis by consensus is sometimes employed, especially when the lesion is quite difficult to interpret, but there is no substitute for seeing the patient or the image or the pathology. One of my teachers, Sadao Otani, M.D. (1892-1969), often said (English was his third language after Japanese and German): “not read books, look at slides.” He did not mean that we shouldn’t read but, instead, was reminding us that, for a pathologist, the specimen is the ultimate truth and, further, the more cases you have the opportunity to study the better a diagnostician/doctor you will be.

2. If you don’t do it, someone else will. This is true in radiology, in pathology and, particularly, in life. Carpe diem – seize the day remains a valuable rule. The Levine article does not enlarge on this but, if I could, I would add “always do the right thing as soon as you think of it.” Sometimes judicious procrastination in watching a case develop is productive, but not usually.

3. Never ask a question that has an answer you don’t want to hear. Trial lawyers know this very well and I have suggested this to my own students many times over the years. My comments were not in the legal sense but rather to suggest that we should try to consider every possible answer to a question before asking it and then ask the question(s) for which we really need an answer.

4. Start where you are. (See #1 above). Laufer was referring to some now archaic device for viewing x-rays but, in a broader sense, was admonishing students to keep your focus and move forward. My version of this, in pathology and in life, is “you can‘t go back in time.” Although I am a lover of history and believe it vitally important to know where we have come from in order to progress (Santayana said: “Those who are ignorant of history are doomed to repeat it”) I firmly believe in avoiding behavior that unnecessarily replicates the past. Look forward, not backward. Too many (politicians and others) fail to understand this concept. In a similar manner, Robert Browning, in his great poem Andrea del Sarto, tells us: “ … a man’s grasp should exceed his reach, Or what’s a heaven for?”

5. Buy our books. Laufer was chiding his students to purchase the books he edited with others. His two corollaries were (a) read our books and (b) give our books as bar mitzvah or Christmas presents. Was this purely meant for jest or was he really telling students that since they’ve already decided to study with him they should take advantage of whatever knowledge he could offer in whatever form it was available? As an author of both medical books and fiction, I heartily agree with this recommendation.

6. The 10% rule. When residents brought food to a noontime conference Laufer used a complex formula (“ … using high-level calculus and quantum mechanics … “) to claim 10% of the food for himself. Dr. Levine indicates that he has adopted that rule and has increased it to 50%, ostensibly in order to help combat the epidemic of obesity. Regrettably, I was unaware of this rule when I was actively engaged in teaching and I wonder if it is another of the forgotten Hippocratic recommendations, perhaps derived from a mistranslation of the Oath (… my teacher … to make him partner in my livelihood, when he is in need of money to share mine with him …).

7. Always buy, never sell. This Laufer rule seems to focus on investment strategy, rather than medicine. However, it has application to the world of large hospitals and, for reasons other than mine, is a good rule for medical center administrators. The current philosophy of healthcare administration seems to be to buy up all the competition so you control as much of the market as possible. My philosophy of competitive health would be to ascribe to this but, in my typically naïve approach (one my writing teachers, Leslie Lehr, has wisely noted that “naïve is pig Latin for stupid”) being bigger should mean that you can afford more of the research, teaching and development necessary to improve healthcare. Unfortunately, the reality is that administrators don’t always appreciate those goals as the principal reason for growth. Hospital systems seem to be indistinguishable in terms of beautiful buildings and fine art work, but not in terms of quality.

8. Don’t be a cheapskate. Penny wise and pound foolish refers to the currency used in England and was first used by the British essayist Joseph Addison in 1712, in his witty newsletter, The Spectator. Igor used this rule in terms of life, rather than just finances. My own grandmother, Fanny Levine Podberesky, in her Polish/Russian/Yiddish/English, said, “You pay cheap, you get cheap.” Avoid the cheap and strive for quality (“cheap” and “quality” are not necessarily, but very often, incompatible). Irwin Shaw, in his short story, The Monument, emphasizes this when the bartender refuses to use the cheap liquor his boss wants to buy, despite the fact that it might only be used in mixed drinks and even if it might cost him his job. Hospital administrators may try to save dollars in laboratories by forcing laboratorians to buy lesser quality instruments and less costly reagents, often despite the evidence and experience available from their pathologists and clinical scientists. My grandmother’s corollary to this rule is: “If they say it’s not the money, it’s probably the money.”

9. Keep it simple. All of the preceding rules can be a part of this one. Medicine and life are both complicated enough without adding to the messiness. Diagnoses are not decided by ballot. Don’t delay, don’t look for magic solutions when you know the right answer, don’t look back, use the best you have—no more, no less—and, follow rule #10.

10. Don’t give up. Igor apparently had a difficult course with his cancer. He is described as responding to the poor prognosis with “dignity, resilience, and grace.” Even with less formidable problems, when convinced of the rightness of one’s judgment, one should never give up. As a Taurus, my task is to make as sure as possible that I am correct since I may have the type of DNA that won’t allow me to give up (I am not always correct, as you can learn from my wife and children). As Tennyson told us, in what may well be the greatest English-language poem ever written, Ulysses: “… and sitting well in order, smite/The sounding furrows; for my purpose holds/To Sail beyond the sunset …”

11. Family first. This seems to speak for itself. It is a straightforward, vital, unquestionably valid rule. This rule was, apparently, paramount to Igor, but I suspect he violated it every now and then to meet urgent patient care needs. Implementation is the problem when you are physician, when you are a pathologist. There’s the school play, PTA meeting/birthday/tennis/ something else, but somebody—the physician and, more importantly, the patient—is waiting for a diagnosis. Unfortunately they usually don’t teach how to balance family needs and obligations in medical school.

12. Start on time. This admonition was apparently for faculty in Laufer’s department, and it should be the rule for everyone in healthcare, for everyone in general. When I moved to Los Angeles more than thirty years ago I immediately observed what colleagues were talking about when they considered “New York time,” “Los Angeles time,” and “hospital time.” Accustomed to Mount Sinai, a hospital where conferences started on time and a medical school where lectures started on time, I never adjusted to this aspect of my new life: nothing in LA started on time. Ever! I once tried to calculate how much time is wasted when the few who do come on time have to wait for whatever it is to begin. It is a lot of time!

13. End on time. Laufer regarded this as even more important than #12 since it potentially impacted other activities. Discipline in achieving this goal is lacking almost as much as it is for rule #12. Often the next speaker, or the next group, just walks into the last minutes of a current session, somewhat hastening the process. Fortunately, there are usually electronic timers for presentations at scientific meetings so this is only rarely a problem in that setting, even/except in LA. As we are all painfully aware, it is also a significant hurdle to overcome for moderators of political debates.

To this impressive list of life rules, I add a few more.

14. Always take the high road. Each and every day we have lots of little choices to make, and occasional big choices to make as well. As we weigh the decision we usually know, deep down in our hearts, what the right thing to do is, even if it is unpopular and makes people unhappy, cost’s money, or violates a rule (and even, rarely, the law). In the end taking the high road—doing the right thing—usually proves to be the best course for the most people. To do less is, in effect, a lie (see #16 below), which will haunt you and hurt others. The frustration comes when others in society seem to have a displaced moral center and your doing the right thing, if in a less powerful setting, has no effect.

15. There is always a high road. Sometimes it takes time and effort to find it.

16. Don’t lie. In the Merchant of Venice, Launcelot tells us: “truth will out.” This is true in life and true in medicine. Scrupulous honesty is assumed to be integral to professionals, such as doctors and lawyers, but there are too many and too often life lessons that belie this. I have, only a few times, had the experience of a surgeon asking me to modify autopsy findings. In both cases I immediately refused. Ironically, in my judgment, the surgeries had been appropriate and the unhappy results were understandable and not due to negligence. In fact, juries are more apt to rule against a physician if there was no autopsy (“the doctor buried his mistakes”) than when a physician requests an autopsy. Autopsy results rarely cause or contribute to judgments against physicians in malpractices cases; when a patient dies it is better for the physician to have requested an autopsy than not.

17. In times of stress be sure to take care of yourself. This is not always easy and takes a conscious effort and regular assessment in the face of a busy and demanding medical/radiology/pathology/other practice or a similarly busy life where you may be consumed by the needs of those around you.

18. Believe in the force. This is not a religious admonition and is not meant for some galaxy, far, far away, although anyone can feel free to interpret it in either of those ways. It is also not a suggestion to look for a light saber. Rather it is a variation of Laufer’s rule #1. If you know how to do something, or know what is right, trust yourself. I have often employed this rule in teaching residents; preparing many slides of grossly identical areas of a specimen is not rewarding—macroscopic (“gross”) pathology (the appearance of a specimen with the naked eye) correlates with microscopic pathology and vice versa. If you have been fortunate enough to be imbued with intelligence and have had the benefit of education, and have good judgment confirmed over time, trust yourself; believe in the force.