When in Rome, Do Like the Romans: Certifying Stroke Centers With the Rod of Aesculapius or the Medical Caduceus of Hermes?

O ne of the first hospitals in the Western world was the Aesculapium which was built in Rome along the Tiber Island in 293 bc and included a long-term recovery center. When the emperor Claudius granted freedom to slaves who had been there for years, it was probably aimed more at disposition of the patients and recovery of the beds they occupied than emancipation. The symbols which reflect the historical tradition of the profession of medicine, and in turn identify for the public those places in which the art of medicine and the principles of Hippocrates are practiced, provide a compelling and relevant perspective. Perhaps the oldest and best known such symbol is the Rod of Aesculapius. It was carried by Aesculapius, the son of Apollo and the Greco-Roman god of medicine. When snakes were said to have licked clean the ears of the young Aesculapius, they taught him secret knowledge that led to him becoming a great healer. He carried a simple rod hewn of wood around which coiled a single serpent, and this rod became a prime symbol of the healing arts (Figure – Panel A). Asclepius died at Zeus’ hand when he angered Hades by accepting gold in payment for resurrecting the dead. While the Rod of Aesculapius remains the predominant symbol of medicine around much of the world, starting in the 1900s in the US a different serpent-themed symbol became equally popular. A double serpent-entwined staff with surmounting wings is often designated as the “medical caduceus” and is derived from the double serpent-entwined staff of Hermes, the Greco-Roman god of commerce (Figure – Panel B). This modern caduceus became a popular medical symbol after its adoption by the US Army Medical Corps at the turn of the 20th century. A 1990 survey of US organizations found that professional associations were more likely to use the Rod of Aesculapius (62%). Hospitals (37%), though, were a notable exception, while commercial organizations were more likely to use the caduceus (76%). This tension between the art of healing and the commercial realities within modern medicine, so simply illustrated in these 2 conflicting symbols of medical care, provides a lens for examining the proper place and method of certification of stroke centers within an altruistic stroke system of care. In their article in this issue of the JAHA, Mullen et al report on an analysis of the use of intravenous thrombolysis and its association with Joint Commission (JC) primary stroke center (PSC) certification, which is potentially an important proxy for superior care delivered at PSC. They used the Nationwide Inpatient Sample to estimate the effect of a hospital’s JC PSC status on the odds of its receiving intravenous tissue type plasminogen activator (IV tPA) in a population of over