The Terrible Trivium; on The Maintenance of Certification, and Academic Promotion

Kishan Dwarakanath, M.D.

Wisdom in the allegory of a Children’s book

I am sure that anyone who grew up reading books will be able to reach far back into their memory and recall influential works whose messages and stories resonate within themselves to the present day. Norton Juster’s “The Phantom Tollbooth” was originally written in 1961. I encountered it in Ms. Nelson’s 4th-grade class in 1988. Rife with wordplay, puns, and a magical-realism, I still read this book nearly yearly. In broad outline, the book tells a story of a young boy, Milo, who is wholly disinterested in acquiring knowledge of the world around him. One day, a magical tollbooth appears in his bedroom. Out of sheer boredom, he drives his small toy car through the tollbooth and suddenly finds himself in “The Lands Beyond”. He meets many memorable characters - Tock the Watchdog, The Spelling Bee, King Azaz of Dictionopolis, and The Mathemagician of Digitopolis. He takes on the mission to rescue the Princesses of Rhyme and Reason from the Mountains of Ignorance. On his quest he encounters “monsters” such as the Everpresent Wordsnatcher, The Senses Taker, and the inspiration for this post: The Terrible Trivium.

The character of The Terrible Trivium presented himself as a well-dressed man but with a completely blank face. In the most polite of ways, The Terrible Trivium asks Milo and his companions to assist him with a series of tasks. Among them, to move a pile of sand from one place to another using only a pair of tweezers. Once set to it, the monster then leans back and smugly (or as smug as one can look with a completely blank face) watches as the heroes of the story toil away. Hour after hour after hour after hour….

Endless Tasks with Little Value

The Terrible Trivium represents the idea of engaging in activities that may seem important on the surface but ultimately have little real value or impact. Similarly, the constant requirements for maintenance of certification (MOC) by the constituent boards of the American Board of Medical Specialities (ABMS) can feel like a series of tasks and exams that demand time, money, and effort without demonstrably contributing anything additional to a doctor's clinical skills or patient care. In order to practice medicine in any US state, licensure must be obtained from the State’s Medical Board and maintained on typically an annual or biannual basis. Continuing Medical Education (CME) has traditionally been part of the requirements to maintain licensure. In recent years, as new challenges have emerged (e.g. the opioid crisis), many state medical boards have adopted requirements for specific topics in CME. This is an entirely reasonable approach and allows individual state medical boards to respond to the unique needs within its own jurisdiction (e.g. State of Texas and human-trafficking training). One must wonder what additional value MOC yields to those who pay the fees and dutifully check-off a seeming endless list of MOC tasks.

Distraction from Meaningful Work

The Terrible Trivium distracted Milo and his companions from their true mission by keeping them occupied with trivial tasks. Similarly, a constant focus on meeting academic promotion criteria can divert physicians from devoting sufficient time and energy to patient care and other genuinely valuable aspects of their profession. The Trivium’s ability to engage people in endless tasks parallels the potential for the pursuit of academic promotion to overshadow actual professional development and learning. Instead of focusing on deepening their knowledge and skills, professionals might find themselves fixated on jumping through bureaucratic hoops. The Terrible Trivium encourages people to become caught up in superficial achievements, disregarding genuine patient-care expertise. A system that places excessive emphasis on participation in powerless committees, generation of journal articles of dubious quality, and ties reimbursement to hierarchical schemes, will tend to devalue practical experience and patient care.

Escalation of the Rat Race and Enhanced Risk of Burnout

The Terrible Trivium perpetuates a cycle of meaningless tasks, which could be seen as analogous to the rat race of academic promotion and maintenance of certification. In both cases, individuals may feel compelled to engage in never-ending cycles of achievement and compliance, often at the expense of their well-being, creativity, and passion for their work. In every way I can imagine, this is a recipe for moral injury and burnout.

How Milo and his companions escaped

Ultimately, Milo and his companions escaped the Terrible Trivium by first recognizing the futility in the tasks he set for them to do. Milo confronts the Trivium:

“But it hardly seems worthwhile.”

When confronted with a logical objection, a reasonable and sincere task-master ought to be able to convincingly articulate the well-considered reasons for the seemingly meaningless tasks at hand. Instead, the Trivium becomes enraged:

“WORTH WHILE!” the man roared indignantly. “Of course it’s not important!” he snarled angrily. “I wouldn’t have asked to do it if I thought it was important.” … as he spoke, he tiptoed slowly toward them with his arms outstretched and continued to whisper in a soft, deceitful voice, “Now do come and stay with me. We’ll have so much fun together. There are things to fill and things to empty, things to take away and things to bring back, things to pick up and things to put down, and besides all that we have pencils to sharpen, holes to dig, nails to straighten, stamps to lick, and ever so much more. Why, if you stay here, you’ll never have to think again…”

The spell was broken and Milo and his companions could finally see the monster for what he truly was only after demanding the Trivium justify the tasks to which he had set them. Like the ABMS boards, like our academic and corporate overlords, the Trivium becomes enraged when challenged. The monster lets slip the contempt he has for the people upon whom he sets his tasks. “I wouldn’t have asked you to do it if I thought it was important” precisely sums up what the ABMS and the administrators on top of academic and corporate hierarchies think of us - the rank and file working physicians. The revenue generators. The workhorses. They seek to keep us so busy with meaningless tasks that we don’t have time to pursue meaningful change and thereby challenge their power and position.

Stay Strong

I fault no physician for playing whatever particular game in which they have found themselves. We have families to house, clothe, and feed. We gotta do what we gotta do and must sometimes acquiesce to what the Trivium demands of us. But let us resolve to call the monster by his name and hold him in as much contempt as he deserves.