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September 1986

The Doctor as Gatekeeper

Author Affiliations

Evanston Hospital 2650 Ridge Ave Evanston, IL 60201

Arch Intern Med. 1986;146(9):1789. doi:10.1001/archinte.1986.00360210177025

Cerberus was the gatekeeper.1,2 For those who missed this mythical dog in high school, or have since forgotten him, Cerberus was the three-headed, scaly-tailed keeper of the gate to Hades. His job was not, however, to keep evildoers out, but to keep them in. It took Hercules (his 12th labor) to remove Cerberus from the gate.

Patients are not evil-doers. Oh, some smoke cigarettes, or eat marbled beef, or forget their blood pressure pills. And I scold or cajole or predict dire consequence. But to the old man with lung cancer I do not say "look what resources you have stolen from us with your addiction." He is no thief from whom I must keep costly care. I do not emphasize to the 40-year-old executive with his second heart attack that his company's health insurance costs will rise because of the marbled beef he ate. He is not wasting

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