Laufer’s rules

By Marc S. Levine, MD, Perelman School of Medicine at the University of Pennsylvania and Hospital of the University of Pennsylvania, Philadelphia, PA

 Dr. Levine is a Professor of Radiology and Advisory Dean in the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Section Chief of Gastrointestinal Radiology in the Department of Radiology at the Hospital of the University of Pennsylvania, Philadelphia, PA. He is also a Member of the Applied Radiology Editorial Advisory Board.

Igor Laufer, MD, my long-time colleague, mentor, and friend in the Perelman School of Medicine at the University of Pennsylvania (Penn), recently passed away after a long battle with cancer. He was an extraordinary gastrointestinal (GI) radiologist, teacher, and innovator who was largely responsible for the development and refinement of modern double-contrast barium studies. Igor also had a Talmudic wisdom in his approach to radiology and life that he incorporated into an indispensable set of guidelines known as Laufer’s Rules. Now that Igor is no longer here, I will present 13 of his rules (in no particular order) along with my interpretations, so radiologists outside Penn may benefit from the perspicacity and insights of this remarkable man and radiologist.

Rule #1: Barium is not a democracy.

In a democracy, the majority rules, with barium, not so much. Even if the majority of images on a double-contrast study fail to show a finding (eg, because of overlapping loops of bowel), the one image that does is the winner. In that sense, practitioners of barium radiology aren’t presidents but dictators, or at best, benign despots. Although this rule needs no further clarification, that didn’t stop Igor from adding 2 corollaries:

Corollary 1A: We don’t vote on the diagnosis.

Corollary 1B: Especially not with the “residinks.”

Pursuant to Corollary 1B, nothing ruffled Igor’s feathers more than a first-year resident (or residink, as he called them) who responded to a question by saying, “In my experience… .” Igor would arch his eyebrows as he cut off the residink in midsentence and pointed out, “You’ve been on the GI service for 2 days. You have no experience.”

Rule #2: If you don’t do it, someone else will.

It could be anything from writing an invited review article to giving a lecture at a refresher course, reviewing a manuscript, or meeting with an x-ray manufacturer about the design of a new product. If you don’t do it, someone else will. What are the chances that another person’s contribution will be anywhere near as valuable as yours? Besides, you need the honorarium a lot more than he or she does.

Rule #3: Never ask a question that has an answer you don’t want to hear.

Asking that question is asking for trouble. Better to let sleeping dogs lie. I myself believe this is one of Igor’s greatest rules, which is why I’ve never asked the chairman of my radiology department why I’m the only one on the faculty who doesn’t take night calls.

Rule #4: Start where you are.

Igor originally intended this rule to apply to the interpretation of old-fashioned x-rays on a conventional film alternator in ancient Greece, a piece of equipment that became obsolete after the invention of the wheel (sorry, digital imaging). These alternators had up to 50 boards on which radiographs were hung, and it drove Igor batty when a residink switched the alternator to the board with the first case rather than starting where he was. That, of course, is because the cases could be reviewed in any order, and it made no sense moving the boards when, as we all know, time is money. Today, film alternators are harder to find than dermatologists who accept Medicare, but in a broader sense, I also think Igor was referring to the importance of keeping your focus and moving forward.

Rule #5: Buy our books.

Igor was referring to 2 books he edited with myself and others, Double Contrast Radiology of the Gastrointestinal Tract and Textbook of Gastrointestinal Radiology, both published by Elsevier (formerly WB Saunders). Though Rule #5 is self-explanatory, Igor added 2 important corollaries:

Corollary 5A: Read our books. (This is optional.)

Corollary 5B: Give our books as Bar/Bat Mitzvah or Christmas presents. (This is not.)

Rule #6: The 10% rule.

This rule is based on complex mathematical equations using high-level calculus and quantum mechanics to show that Igor, by divine right, was entitled to 10% of whatever food the residinks on GI fluoroscopy bought for lunch. This may seem unfair, until you remember that the residinks got to keep the remaining 90%. I have scrupulously adhered to this rule, increasing my share to 50% to help combat the rising epidemic of obesity in America’s young adults.

Rule #7: Always buy, never sell.

This rule referred to Igor’s time-honored strategy for watching your financial investments grow. Being in academic radiology, I never had the opportunity to test this rule myself, but my colleagues in private practice have confirmed that your assets are likely to grow faster if you don’t get rid of them. Incidentally, I’ve been asked by my annoying cousin, the owner of a major league baseball team, when I will have the financial security to retire. I did the math, and it turns out that to pay off my debts and achieve financial solvency I will have to work for 7 more years—after I die. But I digress.

Rule #8: Don’t be a cheapskate.

Igor didn’t necessarily mean in financial terms, but as an approach to life. Wherever you are, whatever you do, don’t be afraid to take chances—to go for the gusto—which is why, for example, Igor tried bullfighting when he was a visiting professor in Barcelona. On a personal note, this kind of thinking got me to join the faculty at Penn as a novice GI radiologist 30 years ago rather than go into private practice. Without the compelling case Igor made for my future, I wouldn’t be the successful academic radiologist I am today. Instead, I’d be lying on some beach in the Caribbean, retired and financially secure. For that, Igor, I thank you.

Rule #9: Keep it simple.

Whether at work or home, Igor was a minimalist at heart. That’s why his reports were shorter than the attention span of most residinks. This minimalist approach also was reflected in his barium studies. In fact, he was a huge devotee of minimalist art, a type of art characterized by simplicity in form and content that enables the audience to view a composition more intensely by removing distractions of theme and personal expression. At least, that’s what it says in Wikipedia.

Rule #10: Never give up.

Igor faced a series of devastating illnesses during his life, but what truly set him apart was his ability to handle adversity with such dignity, resilience, and grace. When confronted with these monumental health challenges, he never surrendered to despair or lost faith, seeing each new setback as a temporary roadblock that could be surmounted through the power of positive thinking.

Rule #11: Family first.

Nothing was more important to Igor than his family. His amazing wife, Bernice, stood by his side through all of the wild loops of his rollercoaster ride, sharing with him the hope and faith that enabled them to endure the many hardships imposed by his cruel disease. And his wonderful children, Miriam and Jacob, infused his life with the love and support he especially cherished during his illness. Last but not least was Caleb, his first grandchild, whom Igor so adored—a ray of sunshine that lit up his life even in the darkest hours.

Rule #12: Start on time.

Igor was absolutely adamant that teachers in radiology always begin their conferences on time. Unless you were reading his book, there was no excuse for making the residinks wait.

Rule #13: End on time.

This was even more important than Rule #12. If a speaker went over his allotted time, he was belittling his students by forcing them to be late for their clinical services and, by association, belittling those clinical services and, by association, the attending on those services.

Well, I’d better stop now. I don’t want to exceed my allotted time. 

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Laufer’s rules.  Appl Radiol. 

February 07, 2012

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