Observations Yankee Doodling

The gatekeeper and the wizard, redux

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3624 (Published 07 September 2009) Cite this as: BMJ 2009;339:b3624
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}rti.org

    An Old World fable exported to America (with apologies and homage to Nigel Mathers1 2 3)

    Once upon a time, in a country far away, lived a great wizard with wondrous healing powers. He lived in a splendid castle on a hill overlooking the city. The wizard was clever. He knew how to use magic crystals to see inside people to find out what was wrong with them, and he had magic spells and potions to treat their illnesses. When sick people came to see the wizard, he often cured them or made them feel better and live longer. For his work he was paid handsomely.

    Down the hill, in a nice big house, though not as grand as the wizard’s, lived a gatekeeper. An important part of her job was to decide who got to see the wizard. She was also clever, and she had magic potions as well. After all, she and the wizard had gone to the same school, though they had learnt different sorts of magic after leaving it. All the people who felt poorly came to see her. For the most part the gatekeeper could tell who needed to see the wizard and who didn’t. She treated most of them herself and sent a few up the hill to see the wizard. She was paid well for her work though not nearly as well as the wizard.

    In olden days there were many more gatekeepers than wizards. This made sense because most people who felt poorly were in fact not terribly ill and were treated extremely well by gatekeepers with their potions. And the few who were very ill got to see the wizard, who used his special crystals and spells on them to good effect.

    But then two things happened.

    Firstly, the costs of the school for wizards and gatekeepers were greatly increased. This led many students to finish school with enormous debts. More and more decided to become wizards rather than gatekeepers because the pay was better. But that meant that now there were too few gatekeepers and too many wizards.

    The second thing that happened was that the rules were changed. Anyone who felt poorly—or even those who didn’t—could go directly up the hill to see the wizard. They no longer had to stop and see the gatekeeper first.

    These two changes led to big trouble.

    Even though wizards were excellent at treating very sick people, it turned out that gatekeepers were much better at telling who was sick and who was not. And gatekeepers charged much less for their magic. Almost everyone who saw a wizard ended up being viewed through magic crystals and treated with spells and potions. And the wizard’s expensive crystals and spells not only cost a lot but didn’t really help people who weren’t very ill, and they sometimes made people worse. Also, there were now so few gatekeepers that many people couldn’t find one. Costs were out of control, lots of people couldn’t afford care when they were sick, and the countryside was in an uproar.

    Then a new prince came to power, young but wise.

    The young prince heard the concerns of the people and gave everyone hope. He promised that everyone who felt poorly could get help. He promised to improve the care that they received. And he also promised to reduce costs. These were difficult promises to keep.

    One big problem was that the prince could not change the rules by himself. To make changes he had to convince the House of Gnomes that his ideas were the best. Everyone agreed that there was a problem, but they disagreed on how to fix it. It was hard work getting a consensus, especially because the gnomes had just agreed to smelt vast piles of gold for the kingdom’s coffers.

    The prince and his courtiers spent most of their time and energy figuring out how to pay for more people to get care. Almost no one talked about who was delivering the care: gatekeepers or wizards. Part of their plan was to control the use of the expensive crystals and spells. And that meant sending everyone to gatekeepers first. But how were people supposed to see gatekeepers first when there weren’t enough of them and when fewer and fewer students were becoming gatekeepers? No one talked about that.

    The storyteller wishes he could tell you that this fable had a happy ending. But this complicated story is not finished. We don’t know yet whether everyone ends up living happily ever after or not.


    Cite this as: BMJ 2009;339:b3624


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