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Essentials of Clinical Informatics
 Essentials of Clinical
Informatics

EDITED BY
MARK E. FRISSE, MD, MS, MBA
AC C ENTUR E PR OFE SSOR OF BIOMEDIC AL IN F ORMAT IC S

V I CE CHAI R FOR BU SIN ESS DEVEL OPMEN T

VAND E R B I LT UNI V E R SIT Y SC H OOL OF MEDIC IN E

N ASH VIL L E, T EN N ESSEE

KARL E. MISULIS, MD, PHD

PR OFE SSOR OF C L IN IC AL N EU ROL OGY

PROFE SSOR OF CLI NI CAL BIOMEDIC AL IN F ORMAT IC S

VAND E R B I LT UNI V E R SIT Y SC H OOL OF MEDIC IN E

N ASH VIL L E, T EN N ESSEE

1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.

Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.

© Oxford University Press 2019

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.

You must not circulate this work in any other form

and you must impose this same condition on any acquirer.

Library of Congress Cataloging-​in-​Publication Data

Names: Frisse, Mark E., editor. | Misulis, Karl E., editor.
Title: Essentials of clinical informatics /​edited by Mark E. Frisse, Karl E. Misulis.
Description: New York, NY : Oxford University Press, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018049155 | ISBN 9780190855574 (alk. paper)
Subjects: | MESH: Medical Informatics | Health Information Systems
Classification: LCC R858 | NLM W 26.5 | DDC 610.285—​dc23
LC record available at https://​lccn.loc.gov/​2018049155

This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
respect to the subject matter covered and to be current as of the time it was written, research and
knowledge about medical and health issues is constantly evolving and dose schedules for medications
are being revised continually, with new side effects recognized and accounted for regularly. Readers
must therefore always check the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers and the most recent
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limiting the foregoing, the publisher and the authors make no representations or warranties as to the
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or incurred as a consequence of the use and/or application of any of the contents of this material.

9 8 7 6 5 4 3 2 1

Printed by WebCom, Inc., Canada

 CONTENTS

Contributors ix

PART I Introduction: Areas of Focus

1. The Healthcare System 3
Mark E. Frisse and Karl E. Misulis

2. Healthcare and the Electronic Health Record 7

Karl E. Misulis and Mark E. Frisse

PART II The Framework

3. Data, Information, and Knowledge 17
Karl E. Misulis and Mark E. Frisse

4. People 23
Mark E. Frisse and Karl E. Misulis

5. Policies, Laws, Regulations, Contracts, and Procedures 29

Mark E. Frisse and Karl E. Misulis

6. Process: The Learning Health System 38

Karl E. Misulis and Mark E. Frisse

PART III The Foundation

7. Representation and Organization of Health Information 45
Karl E. Misulis and Mark E. Frisse

8. Basics of Computers 53
Karl E. Misulis and Mark E. Frisse

9. Design of the Core Healthcare Operating System 69

Douglas J. Dickey, Karl E. Misulis, and Mark E. Frisse

10. Data Repositories 89

Karl E. Misulis and Mark E. Frisse
vi Contents

11. Decision-​Making 104

Karl E. Misulis and Mark E. Frisse

12. Information Systems Strategy and Administration 126

Jeffrey G. Frieling, Karl E. Misulis, and Mark E. Frisse

13. Large-​Project Management 132

Jeffrey G. Frieling, Karl E. Misulis, and Mark E. Frisse

14. Clinician Interface and Experience 152

Paul Weaver, Douglas J. Dickey, Karl E. Misulis, and Mark E. Frisse

15. Access and Access Controls 162

Karl E. Misulis and Mark E. Frisse

16. Analytics 170

Mark E. Frisse and Karl E. Misulis

17. Decision Support 180

Christoph U. Lehmann, Karl E. Misulis, and Mark E. Frisse

18. Security and Privacy 200

Karl E. Misulis and Mark E. Frisse

19. Data Science 219

Karl E. Misulis and Mark E. Frisse

20. Enabling Technologies 224

Karl E. Misulis and Mark E. Frisse

PART IV Application of Informatics in Healthcare

21. Clinical Teams 231
Mark E. Frisse and Karl E. Misulis

22. Patients and Families 236

Karl E. Misulis and Mark E. Frisse

23. Body, Home, and Community 245

Mark E. Frisse and Karl E. Misulis

24. Specialties 248

Karl E. Misulis and Mark E. Frisse
Contents vii

25. Health Information Exchange in Practice 264

Mark E. Frisse and Karl E. Misulis

26. Population Health Management 281

Mark E. Frisse and Karl E. Misulis

27. Researchers 287

Mark E. Frisse and Karl E. Misulis

PART V Future Trends

28. On the Horizon 293
Karl E. Misulis and Mark E. Frisse

29. Staying Current 298

Karl E. Misulis and Mark E. Frisse

PART VI Appendices
Appendix 1. Case Discussions 307
Karl E. Misulis, Jeffrey G. Frieling, and Mark E. Frisse

Appendix 2. Self-​Assessment 317

Karl E. Misulis and Mark E. Frisse

Appendix 3. Reference Data 329

Karl E. Misulis and Mark E. Frisse

Notes and References 343

Index 353
 Visit https://ebookmass.com
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 CONTRIBUTORS

Douglas J. Dickey, MD
Chief Medical Officer of Physician Strategy
Cerner Corporation
Kanas City, MO (Missouri)
Jeffrey G. Frieling, MBA, FACHE
Vice President and Chief Information Officer
West Tennessee Healthcare
Jackson, TN (Tennessee)
Christoph U. Lehmann, MD, FAAP, FACMI, FIAHSI
Professor of Biomedical Informatics and Pediatrics
Vanderbilt University Medical Center
Nashville, TN
Paul Weaver
Vice President, User Experience and Human Factors
Cerner Corporation
Kanas City, MO (Missouri)
 Part I

Introduction
Areas of Focus
 1

The Healthcare System

MARK E. FRISSE AND KARL E. MISULIS ■

OVER VIEW

This chapter focuses on people, processes, policies, and technologies aimed

at improving the health and well-​being of individuals, their families, and their
communities.
The US healthcare system is impressive in so many ways, yet it fails to deliver
reliable, consistent, and affordable high-​quality care to every individual. From the
perspective of patients and providers, the system is a complex and opaque laby-
rinth of processes driven by misaligned incentives and a failure to appreciate the
critical role of culture, behavior, human thought, and problem-​solving processes.1
Although the United States is the most expensive (per capita) healthcare system in
the world, it ranks among the lowest in patient access and health outcomes among
Organization for Economic Cooperation and Development (OECD) countries.2
It is a system overburdened with excessive complexity, number of payers, admin-
istrative requirements, regulatory impositions, and hidden costs. In the future, an
aging population, complex comorbidities, family financial distress, changing cul-
tural expectations, and unsustainable healthcare prices will necessitate a radically
broader view of clinical care. Things must change and clinical informatics must be
up to the task.
4 P a r t I . I n t r oduc t io n : A r eas of  F ocus

ROLE OF INFORMATICS PROFESSIONALS

Clinical informatics professionals historically have concentrated on improving care

through more effective use of electronic medical records (EMRs). Often, these EMRs
were localized to large hospitals and clinics and were entirely disconnected from
mobile devices, consumer products, and a range of other technologies. Often, they
were only clumsily associated with operational, administrative, and billing systems
essential for payment and administration. Over the last decade, federal electronic
health record (EHR) certification requirements, health plan changes, and federal
payment regulations have focused the attention of many clinicians on the admin-
istrative aspects of care, at the expense of time with their patients. There was a time
when physicians did not do anything that did not require a medical degree. Now,
clinicians have become clerical workers.3
Our central challenge is to ensure that clinical informatics professionals under-
stand the forces that drive our healthcare system and employ their understanding
to address the most pressing needs of clinical practice. From this perspective, a mas-
tery of healthcare delivery in hospitals and clinics is necessary but not sufficient.
One heavily cited analysis claimed that clinical care accounts for only 20% of overall
health status. According to this analysis, health behaviors account for 30%, physical
environment (e.g., air, water, housing, transit) accounts for 10%, and social and eco-
nomic factors account for a full 40% (e.g., social support, financial status, education).4
To fix hospitals and clinics, one must look outward and address these other factors.

ROLE OF ADMINISTRATION AND FINANCE

Payment and oversight for clinical services drive much of the day-​to-​day work of
clinicians. Societal expectations, legislation, payment trends, financial constraints,
and many other factors drive the ultimate design of our healthcare delivery system and
the people, processes, data, and technologies used to support this system. Knowledge
of the nuances of mainstream biomedical informatics—​clinical systems—​simply
will not be sufficient to advance healthcare systems increasingly dominated by finan-
cial imperatives. To excel, one must interpret clinical informatics through the lens
of details of federal programs (e.g., Medicare, Medicaid, disability services, Veterans
Affairs [VA], Department of Defense [DoD], Indian Health Service); state programs
(e.g., Medicaid, public health); private insurers (both employer-​sponsored health
plans and pharmacy benefits managers); accrediting bodies; quality improvement
organizations; and certification initiatives. Every clinical informatics professional
must understand how participation in management, support, and delivery can col-
lectively deliver more effective care, improve quality of care, and support research.

THE CUSTOMER: ROLE OF PATIENTS AND FAMILIES

Patients and their families are central. Every individual patient is supported by
an often-​hidden network where many family members, friends, and others work
Chapter 1. The Healthcare System 5

in collaboration to assist with a full range of care activities, including shopping or

transportation, household tasks, finances, personal care and nursing, and indoor
ambulation. The overall composition of these informal patient-​centered care teams
and the roles individuals play are generally not known to providers. To provide ef-
fective care, providers must be aware of both formal and informal caregivers, their
tasks, available devices and technologies in the home, and the broader physical and
cultural environment in which patients live. Clinical informatics professionals must
find means of collecting this information and making it available to improve care
delivery.
The patient perspective is that care is often highly fragmented. Studies showed
that the average elderly patient sees seven doctors across four practices, and that
the average elderly surgery patient is seen by 27 different healthcare providers.5
Providers pay the consequences of this care fragmentation; they sometimes do not
even know who a patient’s other providers are. One study found that the typical
primary care physician must coordinate with 229 other physicians working in 117
practices.6 Hence, in most instances, for a single patient, different individuals will
have different roles reliant on different data sets collected and presented through
multiple technical systems. The EHR of the past must continue to evolve to accom-
modate these realities.
The care fragmentation experienced by patients and providers alike demonstrates
that the EHR would likely best be served by evolving from a database of orders, re-
sult, and documents toward a platform supporting true communication and collab-
oration. Presently, steps are incremental, care quality is uneven, and coordination
is limited.

ROLE OF TECHNOLOGY

Technology’s rapid advancement has not yet led to a mature healthcare technology
infrastructure. Indeed, the rapid evolution of technologies often overwhelm our ca-
pacity to grasp their potential and to incorporate them into our healthcare system. As
a result, some consumers are taking commercial technologies into their own hands
to maintain and monitor health, to monitor chronic disease status, and to commu-
nicate with one another. Data collected through these technologies are seldom in-
corporated into the EHR. Informatics professionals must understand technology
trends and make decisions today that will prepare them for future developments.

ROLE OF ANALYTICS

Providers are faced with a growing and increasingly complex array of quality and fi-
nancial metrics and are increasingly reliant on analytics technologies for their com-
pensation. Researchers, armed with advanced machine learning methods applied to
large data sets, are adding insights to relationships between genetics, behaviors, and
phenotypes derived from EHR and medical claims data. The vast majority of these
more complex analytic approaches are not yet applicable to healthcare delivery and
6 P a r t I . I n t r oduc t io n : A r eas of  F ocus

payment; a focus on fundamental, simple techniques is more cost effective. One

must always remember that new innovations often take several years before their
use and value are widely realized.
Every clinical informatics professional must remain knowledgeable about inno-
vative technologies, yet be advised not to adopt expensive and unstable technologies
while more pressing clinical and financial issues are already apparent.

CLINICAL INFORMATICS PROFESSIONAL SKILL SETS

Clinicians who seek to practice informatics within complex care delivery settings
must be particularly aware of the techniques and skills required to translate their
clinical aspirations into meaningful organizational actions. Informatics is practiced
in the context of teams and organizations united toward common goals. Success
often depends far more on organizational capabilities and immediate needs than on
one’s own knowledge and capabilities. One’s organizational fit is a major determi-
nant of career success.
Mastery of traditional clinical informatics approaches is only the starting point
for a lifetime of effective clinical informatics practice. Much work lies ahead.

KEY POINTS

• Clinical care is only one determinant of health; behavior, social and

economic circumstance, and physical environment play vital roles. Clinical
care requires deep understanding of patients, families, policies, behaviors,
and many other factors.
• Healthcare is delivered by both formal and informal teams composed
of individuals pursuing common goals but playing different roles and
performing different tasks.
• Understanding roles, tasks, and goals is critical both to traditional care
delivery teams and to the informal support care network supporting
patients in their homes.
• Because of demographic trends, care fragmentation, technology
acceleration, and payment methods, EHRs will increasingly be
incorporated into a larger network of systems supporting care
communication, coordination, and accountability.
• New technologies and data sources have the long-​term potential of
transforming clinical care to a dramatic extent but will take time to mature
into actionable programs.
 2

Healthcare and the Electronic

Health Record
KARL E. MISULIS AND MARK E. FRISSE ■

OVER VIEW OF THE ELECTRONIC HEALTH RECORD

IN THE TWENTY-​FIRST CENTURY

The electronic health record (EHR) is the present preferred term for the digital sys-
tems that coordinate healthcare information. The term electronic medical record
(EMR) was used more prominently in the past and has largely been replaced by
current terminology. These terms are not interchangeable. We tend to think of the
EMR as the record an individual facility or provider would use to accomplish what
they previously accomplished with paper records. We think of EHRs as more of a
continuum of records, extending beyond one provider or group of providers and
even beyond the enterprise. Ideally, the EHR would be able to access all medical in-
formation for a particular patient and be able to execute orders across the spectrum
of healthcare services. We aspire to that functional level, but we are not there yet.
Looking to the future, the next step is the personal health record (PHR), for
which healthcare data are governed not by the healthcare institutions but rather
by the patient. As providers, we will interact with the patient’s records using our
electronic tools.
The importance of these conceptual and functional transitions cannot be
underestimated. As authors of this book, we have clinical responsibilities in on-
cology (M.F.) and hospital neurology (K.M.) in addition to our Biomedical
Informatics appointments. These specialties, or almost any other, practiced with
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8 P a r t I . I n t r oduc t io n : A r eas of  F ocus

incomplete information results in life-​and-​death decisions that are difficult and

dangerous.

BASICS OF EHR TECHNOLOGY

There are many functions of the modern EHR, but some key core elements include

• Data storage
• Clinical documentation
• Orders
• Results

Some additional expected functions of a modern EHR include

• Patient list management

• Communication with other providers
• Results inbox with check-​off
• Decision support

These functions are detailed further in this chapter as well as elsewhere in this book.
The beginnings of EHRs included individual applications that performed orders,
provided results, or archived documents. Ultimately, the EHR evolved into a system
that could perform most or all of these tasks.
Presently, the EHR is pervasive in hospitals and most clinics. Estimates are that
more than 95% of hospitals use certified EHR technologies and have achieved
some level of Meaningful Use qualification.1 As of August 2018, the proportion of
hospitals meeting Meaningful Use levels 1 or 2 were as follows2:

• Large hospitals = 99%

• Medium hospitals = 98%
• Small rural hospitals = 98%
• Small urban hospitals = 84%
• Critical access hospitals = 96%
• Children’s hospitals = 78%

Proportions of EHR use by outpatient clinics are somewhat lower, but still substan-
tial. The Centers for Disease Control and Prevention estimated that 87% of outpa-
tient physicians use an EHR in their practice.3
Children’s hospitals were quick to begin the journey to EHR adoption, but in re-
cent years, they have lagged behind adult hospitals and behind children’s hospitals
that are part of adult hospital facilities.4 As a result, they have lagged in Meaningful
Use achievement.5 Among the reasons implicated in this disparity is the greater
inefficiencies of EHRs for pediatric workflow and the challenging finances of many
children’s hospitals.
Chapter 2. Healthcare and the Electronic Health Record 9

Similarly, EHR adoption is less in the outpatient than inpatient arenas. Part of this
is functionality; not all EHRs are equally facile at acute and ambulatory workflows.
Some EHRs are better in outpatient space and some in inpatient space. Part of the
reason for lower adoption is also because, in the ambulatory market, the decision-​
makers for resource utilization are usually the physicians, and they are less likely to
make a substantial investment for a modest incentive payment return.
There are multiple EHR vendors, but there are fewer major players in the market
than there were years ago. Part of this contraction is due to consolidation from
mergers and acquisitions. Part is from sunset of applications that could not keep up
with demands for functionality by users or regulatory agencies. The Office of the
National Coordinator for Health Information Technology (ONC) expects certified
EHRs to have specified functionality, and many vendors without significant market
share have abandoned their segment of the market, not expecting revenues to meet
development costs.
Because of the sunset of some applications, healthcare systems have had to re-
place them with current applications, with the hope that the new apps will not
themselves be sunset. Also, some healthcare systems replace working EHR systems
or subsystems because of hospital or clinic mergers and acquisitions, so that most or
all units of a healthcare system use the same EHR.
Most healthcare systems have more than one functioning EHR, often because
of lags in conversion to an enterprise-​w ide EHR. Also, some specialties prefer
their niche information system. Until a comprehensive EHR can perform the
essentials of the niche systems, the specialty systems will be slow to be replaced.
Examples of where niche systems have significant market penetrance include
radiology’s picture archiving and communication system (PACS) and radi-
ology information system (RIS); oncology EHR (for chemotherapy and radia-
tion therapy); cardiology EHR; and gastroenterology EHR. These systems are
particularly image and procedure based, with complex and unique workflows.
The niche systems accommodate this complexity by generally well-​designed
scripting and workflows, automating many of the tasks required for orders, doc-
umentation, and billing.
Future directions of the EHR will likely be the following:

• Further consolidation of the EHR vendor market

• Transition of enterprises to use fewer and, it is hoped, one principal EHR
• Improved interoperability as part of core functionality
• Transition from niche specialty apps to functionality embedded in
comprehensive system-​wide EHRs
• Focus on user efficiency and productivity
• Connection of EHRs with other EHRs to facilitate point-​of-​care
information exchange and care coordination
• Improvement of clinical decision support function to improve quality of
care, reduce gaps, and control costs
• Improved use of patient-​entered information and facilitation of the move
to the PHR
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reveal [62]a soul and a life that are akin to our own,
more especially in their beginnings, and because they
so wonderfully evoke an age and a country that were
once ours and are still the possession of our grand-
nephews.

At the age of ten the time came for the child to bid a
fresh farewell to his native village. His father was the
first of his race to be tempted by the town, and he
removed his home to Rodez. Jean-Henri was never
again to behold the humble village where he lived “his
best years,” but he bore its image indelibly stamped
upon his mind, upon that part of it in which are formed
those profound impressions that grow more vivid with
the years instead of fading. He left it at first with a light
heart, but later on he was homesick for it; and as the
years went by he felt more than ever its mysterious
attraction, so that one of his last wishes was to see
his grave dug in the shadow of his cradle. But we will
not wrong feelings so delicate by seeking to interpret
them; we will let him speak for himself.

Leaving our native village is no very serious matter when we

are children. We even look on it as a sort of holiday. We are
going to see something new, those magic pictures of our
dreams. With age come regrets; and the close of life is
[63]spent in stirring up old memories. Then, in our dreamy
moods, the beloved village reappears, embellished,
transfigured by the glow of those first impressions; and the
mental image, superior to the reality, stands out in amazingly
 clear relief. The past, the far-off past, was only yesterday; we
see it, we touch it.

For my part, after three-quarters of a century, I could walk with

my eyes closed straight to the flat stone where I first heard the
soft chiming note of the Midwife Toad; yes, I should find it to a
certainty, if time, which devastates all things, even the homes
of Toads, has not moved it or perhaps left it in ruins.

I see, on the margin of the brook, the exact position of the

alder-trees whose tangled roots, deep under the water, were a
refuge for the Crayfish. I should say:

“It is just at the foot of this tree that I had the unutterable bliss
of catching a beauty. She had horns so long … and enormous
claws, full of meat, for I got her just at the right time.”

I should go without faltering to the ash under whose shade my

heart beat so loudly one sunny spring morning. I had caught
sight of a sort of white, cottony ball among the branches.
Peeping from the depths of the wadding was an anxious little
head with a red hood to it. Oh, what unparalleled luck! It was a
Goldfinch, sitting on her eggs.

I know my village thoroughly, though I quitted it so long ago;

and I know hardly anything of the [64]towns to which the
vicissitudes of life have brought me. An exquisitely sweet link
binds us to our native soil; we are like the plant that has to be
torn away from the spot where it put out its first roots. Poor
though it be, I should love to see my own village again; I
should like to leave my bones there. 8

[65]

1 The Château de Saint-Léons standing just outside and above the village of
Saint-Léons, where the author [40]was born in 1823. Cf. The Life of the Fly,
chaps. vi. and vii.—A. T. de M. ↑
2 The brother whom Fabre here associates with the memories of his childhood has
also proved a credit to his name and his vocation. M. Frédéric Fabre is to-day
Director of the Crillon Canal and assistant justice for the southern canton of
Avignon. ↑
3 Souvenirs, VIII., pp. 126, 127; Bramble-Bees, chap. xiii, “The Halicti.” ↑
4 The war of 1830 with Algiers.—A. T. de M. ↑
5 Souvenirs, pp. 260–270. The Life of the Fly, chap. vii., “The Pond.” ↑
6 The Wheat-ear, one of the Saxicolæ, is known also as the White-Tail, the
meaning of both forms being the same; White-ear being a corruptive of the
Anglo-Saxon name. Both correspond with the Provençal Cul-blanc. The Stonechat
is a member of the same genus. B. M. ↑
7 Souvenirs, pp. 292–300. The Life of the Fly, chap. xvii., “Recollections of
Childhood.” ↑
8 Souvenirs, VIII., pp. 125–129. Bramble-bees, chap. xiii., “The Halicti: The
Portress.” ↑
[Contents]
CHAPTER V
 AT THE COLLEGE OF RODEZ
We have learned what we may of the schoolboy of
Saint-Léons. Let us follow him to the Lycée of Rodez,
which he entered as a day-boy at the age of ten:

I come to the time when I was ten years old and at Rodez
College. My functions as a serving-boy in the chapel entitled
me to free instruction as a day-boarder. There were four of us
in white surplices and red skull-caps and cassocks. I was the
youngest of the party, and did little more than walk on. I
counted as a unit; and that was about all, for I was never
certain when to ring the bell or when to move the missal from
one side of the altar to the other. I was all of a tremble when
we gathered, two on this side, two on that, with genuflexions,
in the middle of the sanctuary, to intone the Domine, salvum
fac regem at the end of mass. Let me make a confession:
tongue-tied with shyness, I used to leave it to the others.

Nevertheless, I was well thought of, for, in the school, I cut a

good figure in composition and translation. In that classical
atmosphere there was talk [66]of Procas, King of Alba, and of
his two sons, Numitor and Amulius. We heard of Cynægirus,
the strong-jawed man, who, having lost his two hands in
battle, seized and held a Persian galley with his teeth, and of
Cadmus the Phœnician, who sowed a dragon’s teeth as
though they were beans, and gathered his harvest in the
shape of a host of armed men, who killed one another as they
rose up from the ground. The only one who survived the
slaughter was one as tough as leather, presumably the son of
the big back grinder.
 Had they talked to me about the man in the moon, I could not
have been more startled. I made up for it with my animals,
which I was far from forgetting amid this phantasmagoria of
heroes and demigods. While honouring the exploits of
Cadmus and Cynægirus, I hardly ever failed, on Sundays and
Thursdays, to go and see if the cowslip or the yellow daffodil
was making its appearance in the meadows, if the Linnet was
hatching on the juniper-bushes, if the Cockchafers were
plopping down from the wind-shaken poplars. Thus was the
sacred spark kept aglow, ever brighter than before. 1

At Rodez, as at Saint-Léons, natural objects provided

him with the chief material of his recreations:

The thrice-blessed Thursday had come; our bit of translation

was done, our dozen Greek roots had [67]been learnt by heart;
and we trooped down to the far end of the valley, so many
bands of madcaps. With our trousers turned up to our knees,
we exploited, artless fishermen that we were, the peaceful
waters of the river, the Aveyron. What we hoped to catch was
the Loach, no bigger than our little finger, but tempting, thanks
to his immobility on the sand amid the water-weeds. We fully
expected to transfix him with our trident, a fork.

This miraculous catch, the object of such shouts of triumph

when it succeeded, was very rarely vouchsafed to us; the
Loach, the rascal, saw the fork coming and with three strokes
of his tail disappeared!

We found compensation in the apple-trees in the

neighbouring pastures. The apple has from all time been the
urchin’s delight, above all when plucked from a tree which
does not belong to him. Our pockets were soon crammed with
the forbidden fruit.
 Another distraction awaited us. Flocks of Turkeys were not
rare, roaming at their own sweet will and gobbling up the
Locusts around the farms. If no watcher hove in sight, we had
great sport. Each of us would seize a Turkey, tuck her head
under her wing, rock it in this attitude for a moment and then
place her on the ground, lying on her side. The bird no longer
budged. The whole flock of Turkeys was subjected to our
hypnotic handling; and the meadow assumed the aspect of a
battle-field strewn with the dead and dying.

And now look out for the farmer’s wife! The [68]loud gobbling
of the harassed birds had told her of our wicked pranks. She
would run up armed with a whip. But we had good legs in
those days! And we had a good laugh too, behind the hedges,
which favoured our retreat!

How did we, the little Rodez schoolboys, learn the secret of
the Turkey’s slumber? It was certainly not in our books.
Coming from no one knows where, indestructible as
everything that enters into children’s games, it was handed
down, from time immemorial, from one initiate to another.

Things are just the same to-day in my village of Sérignan,

where there are numbers of youthful adepts in the art of
putting poultry to sleep. Science often has very humble
beginnings. There is nothing to tell us that the mischief of a
pack of idle urchins is not the starting-point of our knowledge
of hypnosis. 2

The incident of which we have just read was the

starting-point of the investigations which Fabre was
to undertake fifty years later concerning the artificial
sleep of birds and insects.
If he had hearkened only to his passion for Nature,
the schoolboy of Rodez would soon have become
one of the most ardent disciples of the school of the
woods; that is, [69]he would have played truant. But he
was, happily, from an early age, a worker; because
industry was for him both a family inheritance and an
imperious necessity. Had he not been sent to college
on condition of winning prizes? Could he show
himself an idle scholar when he saw his parents
wearing themselves out in order to supply the needs
of their family? Moreover, as he rose from class to
class, the love of learning increased within him. Latin
ceased to be repulsive, and became even wholly
sympathetic, when he found, in the fifth class, thanks
to the genius of Virgil, that it dignified the humble joys
of rural life by the emphasis of skilfully chosen words
and brilliant colours of the poet:

By easy stages I came to Virgil, and was much smitten with

Melibœus, Corydon, Menalcas, Damœtas, and the rest of
them. The scandals of the ancient shepherds fortunately
passed unnoticed; and within the frame in which the
characters moved were exquisite details concerning the Bee,
the Cicada, the Turtle-dove, the Crow, the Nanny-goat, and
the golden broom. A veritable delight were these stories of the
fields, sung in sonorous verse; and the Latin poet left a lasting
impression on my classical recollections. 3

[70]
Traces of Virgil are often visible—more often than
those of the other classical writers—in the work of
Fabre. He loves to embellish his narratives with
quotations borrowed from the writer of the Bucolics
and the Georgics, and he loves also to evoke the
happy days of his boyhood at Rodez behind the
lineaments of the Virgilian idylls, which were far more
akin to the taste of his age and the instinct of his
genius than the Metamorphoses of Ovid or Religion
of Louis Racine, who shared, with the Mantuan, the
privilege of providing the young humanist of 1835 at
the Rodez lycée with literary exercises.

All roads lead to Rome. It is enough that they do so.

Without sacrificing any of the demands of the
classics, by way of analogy or by way of antithesis,
the child’s mind was constantly escaping from his
books toward the things of Nature and Life.

In its free, palpitating flight his thought kindled his

imagination, and with indescribable emotion he
began to touch upon more serious questions:

The problem of life and that other one, with its dark terrors,
the problem of death, at times passed through my mind. It
was a fleeting obsession, soon forgotten by the mercurial
spirits of [71]youth. Nevertheless, the tremendous question
would recur, brought to mind by this incident or that.
Passing one day by a slaughter-house, I saw an Ox driven in
by the butcher. I have always had an insurmountable horror of
blood; when I was a boy, the sight of an open wound affected
me so much that I would fall into a swoon, which on more
than one occasion nearly cost me my life. How did I screw up
courage to set foot in those shambles? No doubt, the dread
problem of death urged me on. At any rate, I entered, close
on the heels of the Ox.

With a stout rope round its horns, wet-muzzled, meek-eyed,

the animal moves along as though making for the crib in its
stable. The man walks ahead, holding the rope. We enter the
hall of death, amid the sickening stench thrown up by the
entrails scattered over the ground and the pools of blood. The
Ox becomes aware that this is not his stable; his eyes turn
red with terror; he struggles; he tries to escape. But an iron
ring is there, in the floor, firmly fixed to a stone flag. The man
passes the rope through it and hauls. The Ox lowers his
head; his muzzle touches the ground. While an assistant
keeps him in this position with the rope, the butcher takes a
knife with a pointed blade; not at all a formidable knife, hardly
larger than the one which I myself carry in my breeches-
pocket. For a moment he feels with his fingers at the back of
the animal’s neck and then drives in the blade at the chosen
spot. The great beast [72]gives a shiver and drops, as though
struck by lightning: procumbit humi bos, as we used to say in
those days.

I fled from the place like one possessed. Afterwards I

wondered how it was possible, with a knife almost identical
with that which I used for prizing open my walnuts and taking
the skin off my chestnuts, with that insignificant blade, to kill
an Ox and kill him so suddenly. No gaping wound, no blood
spilt, not a bellow from the animal. The man feels with his
finger, gives a jab, and the thing is done: the Bullock’s legs
double up under him.
 This instantaneous death, this lightning-stroke, remained an
awesome mystery to me. It was only later, very much later,
that I learnt the secret of the slaughter-house, at a time when,
in the course of my promiscuous reading, I was picking up a
smattering of anatomy. The man had cut through the spinal
marrow where it leaves the skull; he had severed what our
physiologists have called the vital cord. To-day I might say
that he had operated in the manner of the Wasps, whose
lancet plunges into the nerve-centres. 4

This gloomy picture of a sudden, terrifying, violent

death may be compared with another which, in some
respects, is even more tragic: that of the ruined home
and the shattered [73]life of the little Rodez schoolboy,
who was to leave the town somewhat as he left the
slaughter-house, bewildered by the catastrophe of
which he had just been the witness and was soon to
be the victim. At this point of his narrative his eyes
are dim with tears and his voice is choked by a half-
suppressed sob.

Then, suddenly, good-bye to my studies, good-bye to Tityrus

and Menalcas! Ill-luck is swooping down on us, relentlessly.
Hunger threatens us at home. And now, boy, put your trust in
God; run about and earn your penn’orth of potatoes as best
you can. Life is about to become a hideous inferno. Let us
pass quickly over this phase.

Amid that lamentable chaos my love for the insect ought to

have gone under. Not at all. It would have survived the raft of
the Medusa. I still remember a certain Pine Cockchafer met
for the first time. The plumes on her antennæ, her pretty
 pattern of white spots on a dark-brown ground were as a ray
of sunshine in the gloomy wretchedness of the day. 5

[74]

1 Souvenirs, VI., p. 60. The Life of the Fly, chap. vi., “My Schooling.” ↑
2 Souvenirs, VII., pp. 29, 33. The Glow-Worm and Other Beetles, chap. xv.,
“Suicide or Hypnosis?” ↑
3 Souvenirs, VI., p. 61. The Life of the Fly, chap. vi., “My Schooling.” ↑
4 Souvenirs, II., pp. 41–44, 46. Hunting Wasps, chap. xx., “A Modern Theory of
Instinct.” ↑
5 Souvenirs, VI., p. 61. The Life of the Fly, chap. vi., “My Schooling.” ↑
[Contents]
CHAPTER VI
 THE PUPIL TEACHER: AVIGNON
(1841–43)
The stroke of misfortune which suddenly interrupted
Jean-Henri’s studies at the Rodez lycée made him
an exile from his father’s house and banished him
from his native countryside.

For the second time he was, as it were, dropped

upon the road like Perrault’s Tom Thumb. And the
fairy-tale comes to life again in the Odyssey of the
poor boy who wandered at random, picking up his
food at hazard, facing misfortune with a stout heart,
and smiling whenever he could at the poem of
Nature, who always had some fresh surprise in store
for him.

Who can fail to be moved by pity and admiration,

beholding him set forth upon the broad, white
highroads, a wandering child, all but lost, seeking his
way, seeking his livelihood even, without other relief,
in his extremity of distress, and almost without other
food than his love of Nature and his passion [75]for
learning? See him, for example, on the day when,
between Beaucaire and Nîmes, he contrived to make
his dinner off a few bunches of grapes “plucked
furtively at the edge of a field, after exchanging the
poor remnant of his last halfpence for a little volume
of Réboul’s poems; soothing his hunger by
intoxicating himself with the verses of the workman
poet,” 1 whose inspiration was of so noble and
Christian a character.

The whole Fabre is in this trait of the needy,

enraptured youth, who thinks nothing of hardships or
of money provided he can find the wherewithal to
assuage his thirst for knowledge and the ideal.

Nevertheless, it is true that he passed through many

dark and painful hours at that period. But in the end
“the good fortune that never deserts the valiant”
opened the doors of the Normal College of Avignon
for him. Having ventured to face the examination for
a bursary, he won the latter with the greatest ease.
There he found a first refuge from the uncertainties of
the morrow, although he had not yet achieved his
ideal, nor even that place in the sun which he was
[76]striving to prepare for himself. Imagine “between

four high walls a courtyard, a sort of bear-pit in which

the scholars contend for room beneath the boughs of
a plane-tree; and opening on to it, on every side, the
class-rooms, like so many cages for wild beasts,
devoid of daylight or air.” This was the Normal
College of Vaucluse.

The description recalls, in some respects, that which

was given by a sometime pupil of the Normal College
of Paris, M. René Doumic, on taking his seat in the
Academy, in the place of Gaston Boissier: “I loved
the Normal College, and I am still faithful in my
attachment to it. I hope my recollections of it will not
be thought lacking in piety if I state that the building
in which they penned us up, young fellows of twenty,
was the most dismal place that I have ever seen
anywhere. This extraordinary building, by an
architectural prodigy which I will not attempt to
explain, turned all four sides to the north. In three
years I do not think I ever saw a single ray of sunlight
enter our lecture-rooms or the cloisters in which we
used to wander like so many shades. A mournful
daylight expired upon the grey, grimy walls. In short,
it was not a cheerful place. But at Boissier’s lectures
all became [77]bright, full of animation and renewed
life. It was a sudden metamorphoses.”

At the Normal College of Vaucluse it was not the

lectures given by the masters that transformed the
abode of shades or the bears’ cage into a centre of
light and life for the budding biologist. It was
something better than that. By good fortune the
director of the College was broad-minded enough to
allow him to employ in his own fashion all the time
that was left to him after he had prepared his lessons
and his exercises. We may imagine that he did not
loiter over his classics. The school programme, for
that matter, was not very heavy; the orthographic
difficulties which complicated most of the exercises
of the future schoolmasters were mere play to the ex-
Latinist of the Rodez lycée. And “while all around him
dictated passages were being minutely scanned with
much searching of the dictionary, he examined, in the
secrecy of his desk, the fruit of the oleander, the
flower of the snapdragon, the sting of a Wasp, the
wing-cover of a gardener-beetle.” Thus he treated
himself to a lecture of his own fashion whose charm
and fascination greatly exceeded that of anything
that the college could teach him.

So much so that he left the College more [78]in love

than ever with insects and flowers, and thoroughly
determined to fill what he considered to be one of the
most serious deficiencies of official instruction.

Alas! there were many deficiencies in the education

received by his masters which would have to be
made good in order to complete the literary
education which the professors of the Rodez lycée
had begun to give him, and the scientific training
which he had hardly commenced at the Normal
College.

We must listen to his reminiscences of his career as

pupil teacher, to the inventory of the scientific
equipment of a schoolboy of 1840, to the story of his
first and last lesson in chemistry, to see how poor he
was in acquired knowledge and how rich in the
desire for knowledge, before we can estimate the
length of the road which he had to travel when he
had passed through the classes of the College.

In my normal school, the scientific teaching was on an

exceedingly modest scale, consisting mainly of arithmetic and
odds and ends of geometry. Physics was hardly touched. We
were taught a little meteorology, in a summary fashion: a word
or two about a red moon, a white frost, dew, snow and wind;
and, with this smattering of rustic physics, we were
considered to know enough of the [79]subject to discuss the
weather with the farmer and the ploughman.

Of natural history, absolutely nothing. No one thought of

telling us anything about flowers and trees, which give such
zest to one’s aimless rambles, nor about insects, with their
curious habits, nor about stones, so instructive with their fossil
records. That entrancing glance through the windows of the
world was refused us. Grammar was allowed to strangle life.

Chemistry was never mentioned either: that goes without

saying. I knew the word, however. My casual reading, only
half-understood for want of practical demonstration, had
taught me that chemistry is concerned with the shuffle of
matter, uniting or separating the various elements. But what a