You are using an outdated browser. Please upgrade your browser to improve your experience.
Become a Fellow
ACP offers a number of resources to help members make sense of the MOC requirements and earn points.
Understanding MOC Requirements
Earn MOC points
The most comprehensive meeting in Internal Medicine.
April 11-13, 2019
Internal Medicine Meeting 2019
Prepare for the Certification and Maintenance of Certification (MOC)
Exam with an ACP review course.
Board Certification Review Courses
MOC Exam Prep Courses
Treating a patient? Researching a topic? Get answers now.
Visit AnnalsLearn More
Visit MKSAP 18Learn More
Visit DynaMed Plus
Ensure payment and avoid policy violations. Plus, new resources to help you navigate the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Access helpful forms developed by a variety of sources for patient charts, logs, information sheets, office signs, and use by practice administration.
ACP advocates on behalf on internists and their patients on a number of timely issues. Learn about where ACP stands on the following areas:
© Copyright 2018 American College of Physicians. All Rights Reserved. 190 North Independence Mall West, Philadelphia, PA 19106-1572
Toll Free: (800) 523.1546 · Local: (215) 351.2400
Ambrose Bierce and the Devil's Dictionary
by Clifton R. Cleaveland, MD, MACP
Tennessee ACP Chapter Meeting
Nashville, 11 March 2002
Consider a sampler of terms from The Devil's Dictionary
by Ambrose Bierce:
Physician - one upon whom we set our hopes when
ill and our dogs when well.
Our profession was not the only one to earn the attention of the
19th century's most accomplished American satirist.
Dentist - A prestidigitator who puts metal
into your mouth and pulls coins out of your pocket.
And then there were lawyers; lawyer - one
skilled in the circumvention of the law. And
litigation - a machine which you go into as a
pig and come out as a sausage.
Bierce saved his most pointed arrows for practitioners of the
noble art of politics, defining a politician
as an eel in the fundamental muck upon which the superstructure
of organized society is reared. When he wriggles he mistakes the
agitation of his tail for the trembling of the edifice. As compared
with the statesman, he suffers the disadvantage of being
alive. Politics comes off as a strife of
interests masquerading as a contest of principles. The conduct of
public affairs for private advantage.
In light of Enron, Worldcomm, Tyco and other megabusinesses
recently fallen from grace, listen to Bierce's definition of the
corporation: an ingenious device for obtaining
individual profit without individual responsibility.
Who was this practitioner of such audacious calumny? Ambrose
Bierce was born 24 June 1842 in the backwoods of Southeastern Ohio,
the tenth of thirteen children. His father, Marcus Aurelius,
insisted upon naming each child with a name beginning with the
letter "A." The family lived in desperate poverty. In a childhood
marked by unrelenting duty to parents, farm and fundamentalist
church Ambrose did find time to read voraciously.
At fifteen he left home to become first a printer's devil. Next
he spent a year at the Kentucky Military Institute before enlisting
in 1861 in the Union Army. He found a home in the Army and rose to
the rank of brevet major by war's end. He fought in the battles of
Nashville, Chickamauga, and Kennesaw Mountain where he was shot in
the head, the bullet penetrating his skull and coming to rest
behind his ear. After a brief convalescence he returned to combat,
was captured, escaped and served to until the war concluded. After
a stint working for the US Treasury Department in Alabama, he
joined a military expeditionary force sent to explore the territory
lying between Nebraska and California.
Reaching San Francisco, he resigned from the army and took a job
as a night watchman. He had decided to become a writer, and after
extensive practice while on the job, he found markets for his
various prose pieces in San Francisco publications. His pungent
prose soon appeared in the papers and magazines of Eastern cities.
In 1871 he married wealthy Mollie Day, whose father financed a trip
to London for the couple on the condition that they would take Mrs.
Day off his hands. There the threesome would remain for four years.
Ambrose found ready markets for his prose in British periodicals.
Commissions, however, were insufficient to support him. After his
return to America Bierce worked in the US mint until he could
establish literary connections. Eventually he would compose columns
for three San Francisco weeklies. William Randolph Hearst hired the
fiery journalist to write a weekly column for the San Francisco
Examiner. He reveled in exposing fools and foolishness. He composed
verse, satiric fables, essays, and short stories. He carefully
cultivated a talent for making enemies in the same fashion as H. L.
Menchen decades later. Bierce collected some of his favorite barbs
in The Devil's Dictionary.
Always restless for adventure, Bierce set out in 1913 for Mexico
to join the army of Pancho Villa. His exact fate remains unknown.
The movie, The Old Gringo, wonderfully captures the man
and the times.
In honor of Ambrose Bierce, who after all, came through our part
of the country, I thought it only fitting to update The Devil's
Dictionary in light of some of the terminology and its
purveyors whom we daily encounter.
Let us begin with capitation - a noun, an
advanced mathematical concept by which the health care dollar is
divided into three equal halves, one to be allocated to
administrators of various stripes, one to sellers of hospital
services and medications, and one to remain in perpetual flux, only
occasionally showing up on the balance sheets of physicians.
From capitation it is easy to move to
precertification - a noun, an administrative
structure designed to assure that medical care is more likely to be
We are clearly on a roll now. Captitation and precertification
are fundamental to HMO - a noun, derived from the
term HUMONGOUS to denote the unrestrained power of a system
designed to trash the doctor-patient relationship.
Another derivation is HIPPA, the newly released
set of regulations dealing with confidentially of clinical records.
Our updated Devil's Dictionary would see this as a noun,
an abbreviation of HIPPOPOTAMUS, designating a large clumsy entity
that mindlessly stomps all in its way.
Instead of limiting our barbs to corporate and governmental
enterprises, let us consider some of our own.
RK or radial keratotomy -
noun, procedure for correcting myopia so that the charge for the
procedure can be read by the patient without glasses before he
swoons; alternatively, an income redistribution technique
permitting the purchase of vacation homes by ophthalmologists.
And how about Botox, another noun, substance
that smoothes wrinkles out of overfilled billfolds of patients.
From Bo Derek, sometime movie actress.
And while we are in the area of plastic or aesthetic surgery,
there is liposuction, a noun, technique for
debulking a hulk; alternatively, a French kiss.
MRI in our updated dictionary becomes,
abbreviation for Mighty Reimbursement Machine.
In the vocabulary of our daily work, we find unformed
stool - a noun, furniture kit from Crate and Barrel.
And guaiac - failed line of General Motors
automobile named for Indian chief of same name.
Scientific progress necessitates the creation from time to time
of new subspecialties. Certainly it is time to recognize
procto-ophthalmology - subspecialty dealing with
visual handicaps of Medicare administrators.
Ranging further afield, how about mural
dyslexia - a noun, the inability to read the handwriting
on the wall when one's back is up against it.
I have saved the most difficult etymology to last, namely
TennCare. Many people erroneously assume the Tenn
in TennCare is an abbreviation for Tennessee. This is definitely
not the case. My initial research suggested that "Tenn" came from
"tenaculum"-the small, sharp-pointed hook set in a handle, used for
seizing and picking up parts in operations and dissections.
Certainly the sharpness and the seizure are appropriate to the
insurance plan. Further study produced "tentative"-meaning
experimental, done as a trial or attempt. That derivation of the
"Tenn" is quite apt. Finally, reference to ancient manuscripts
indicated quite clearly that "Tenn" was short for "tenesmus"-a
straining to defecate or uninate without the ability to do so.
Combining the three origins I propose TennCare, a
noun, a sharp-edged experiment in the financing of health care,
characterized by much straining but with no delivery.
So what is my point? In the latter decades of the 19th century,
Ambrose Bierce looked at the explosive growth and chaos as the new
city of San Francisco changed from trading post to burgeoning
metropolis. He looked beyond facades of wealth and fashion to call
attention to people left behind. His enemies were pomposity,
arrogance, and mindless bureaucracy. His allies were common
Healthcare in our day exhibits similar exuberant and chaotic
growth. Finite energies and dollars routinely are squandered in
supporting administrative structures that serve neither the
interests of patients nor those seeking to care for them. Fortunes
are made in the health care industry, yet many of our fellow
citizens find it ever harder to obtain basic medical care, and
indeed many good practitioners who find their fulfillment in caring
for the sick and injured are driven crazy by mindless
Satire allows us to pause, to take notice, to scoff if
necessary. Satire allows us to separate substance from the
ephemeral. Satire can expose the emperor when he has no clothes.
Satire when combined with reasoned, clearly articulated arguments
on behalf of our patients and our basic ethical concerns as
physicians can arrest the steady erosion of health care by forces
more interested in wealth than in health.