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FACTUAL RECORDS HELP PROVE CONTRIBUTORY FAULT (PACE 7) *1 IL417L V.8 NO.t 1S96 C.01 SEq: SR0063601 Ti: ILLINOIS MEDICINE 01/24/96 Students, residents must examine each A literary look other at pathology PAGE 8 ILLINOIS STATE MEDICAL SOCIETY • JANUARY 19 1996 DOI drops proposed amendment regarding HCFA 1500 claim form UPDATE: Physicians must use universal claim form for billing insurers but not for billing patients directly. BY KATHLEEN FURORE SPRINGFIELD Respond- the legislation. The exemption The department kept in [ ] ing to concerns expressed by applies only to direct patient mind “comments with respect ISMS and the American Dental billing. to superbills and [the] HCFA Association, the Illinois Depart- The act, which Edgar signed 1500 form,” DOI Director ment ofInsurancewill remove a in September 1994, requires Mark Boozell wrote in a Dec. proposed amendment to the “providers of health care or 11, 1995, letter to a physician Uniform Medical Claim and treatment, medical services, who had expressed his concerns ATTENDEES listen to presentations about the employ- Billing Forms Act that would dental services, pharmaceutical in a letterto Gov.Jim Edgar. have required physicians and services or medical equipment” “We are going to remove the er-provider relationship at the Nov. 30 symposium other health care providers to to use the HCFA 1500 universal language that states practition- “Health Reform at the Community Level” at the use the HCFA 1500 universal claim form for all bills submit- ers have to use the 1500 form Westin Hotel in Chicago. The program was sponsored claim form for direct patient ted to insurers as of Jan. 1, to bill patients directly,” by ISMS and the Midwest Business Group on Health. billing, according to Ron 1996. Doctors now must use Kotowski said. The DOI’s Kotowski, assistant deputy the forms to provide informa- intent was to prevent physicians director of the Life and Health tion about a patient’s medical from billing patients instead of Compliance Section of the Illi- diagnosis, treatment and prog- insurers if those patients would Chicago-area physicians nois Department of Insurance. nosis, as well as to list charges ultimately have submitted the ISMS and the ADA opposed the in conformity to the proof bills to payers. In a recent amendment, which ISMS Chair- requirements of an insurance phone survey of insurers, the merge practices to create PO man of the Board Ronald G. policy or a hospital, medical or department learned that payers Welch, MD, said “clearly goes dental service contract, accord- do not receive a significant beyond the statutory intent” of ingto the legislation. (Continuedonpage 14) ORGANIZATION: Primary care doctors form Mid-America Medical Group, byKathleenfurore INSIDE ISMS workshop focuses on [ OAK BROOK TERRACE ] about merging my practice - it Hoping to maintain clinical was a bold step,” said James physician-driven entities autonomy and high-quality Dan, MD, president ofthe Mid- Seminar helps patient care, 63 primary care America Medical Group. “But physicians in DuPage and west as Norm Webb says, we’re giv- residents In January and February, ISMS members have the oppor- Cook counties have merged ing up management autonomy tunity to attend a Society workshop that provides an in- negotiate, their practices and the assets of to preserve clinical autonomy. depth look at successful physician-driven managed care interview their 23 businesses to create the We don’thave tocallevery 800- organizations. The three-and-a-half-hour program is free Mid-America Medical Group, a number [for permission to treat and is being conducted at various locations across the physician organization. a patient]. We’re trying to con- state, including the Chicago Medical Society’s Midwest “This is an organization trolmedical quality.” Clinical Conference in Chicago. The workshop informs owned by doctors to run doc- Morgan Meyer, MD, a mem- members about ISMS’ proposed Physician Services Orga- tors,” said Norman Webb, chief ber ofthe new group and a past nization, state and national market trends and managed executive officer of the group’s president of ISMS, also said the care under capitation. management services organiza- PO will alleviate bureaucratic The workshop was held in Peoria on Jan. 17 and in tion. “Being a fully integrated hassles. “We felt we would have Springfield on Jan. 18. Programs will also be conducted group practice gives the physi- better clout if we were running in Champaign on Jan. 24 atJumer’s Castle Lodge, 209 S. DEPARTMENTS cians economies of scale. They our own show and not having Broadway; in Rockford on Feb. 7 at the Clock Tower share staff, lawyers, accountants. everyprescription questioned.” Inn, 7801 E. State St.; in Carbondale on Feb. 8 at the News Briefs 2 It reduces their outside consult- The physician organization, Holiday Inn-SIU, 800 E. Main St.; and in Collinsville on ing fees.” It alsoenabled the doc- which is organized into four Feb. 15 at the Holiday Inn Collinsville, 1000 Eastport Commentary.... 4 tors to purchase a more sophisti- areas covering the western sub- Plaza Drive. Each workshop runs from 5 to 9 p.m., and cated informationsystem. urbs, was begun in early 1995 dinner is provided. ISMIE Update 7 “I certainly had my concerns (Continuedonpage 14 .. Please watch your mail for more information or call the ISMS division of governmental affairs at (800) 782- Classifieds ...11 ISMS. In addition, look for coverage in Illinois Medicine. A special session of the workshop will be conducted ******Mt********** 3-OIGIT 203 at CMS’ Midwest Clinical Conference on Jan. 20 at the Obituaries ...15 NATIONAL LIB OF MED 00542 & TS-INDEX MEDICUS Sheraton Chicago Hotel Towers, 301 E. North Water IDPR 3600 ROCKUILLE PIKE St. Separate registration is required. Disciplines .........15 BETHESDA MD 20894-0001 2 • ILLINOIS MEDICINE JANUARY 19 1996 News Briefs Transportation safety board issues air bag warning STATE REP. Ann Hughes (R-McHen- WASHINGTON The National crushing brain injuries “as a result ofthe T[ransportation Safety] Board is asking impact ofthe air bag compartment cover ry) spoke to physi- hospitals and physicians to help warn flap with the back ofthe child safety seat cians about tort re- the public about the risk that air bags at the location of the child’s head,” form legislation at pose to infants and small children. After Hall’s letter said. It advised hospitals to the McHenry Coun- studying seven recent low-impact acci- issue the same warning to participants in ty Medical Society dents in which passenger-side air bags childbirth education programs and other were deployed, killing, or severely injur- new parenting classes. The board also dinner meeting, held ingchildren, the organization announced recommended that members of the Dec. 20 in Algonquin. its decision to conduct an education American College of Obstetricians and campaign. Gynecologists, the American Academyof “The safety board believes that in Family Physicians and the American each of the accidents the child would Academy of Pediatrics issue the air bag have survived the accidentwith minor or warning. no injuries had the air bag not been Infants are not the only ones in dan- deployed,” said NTSB Chairman Jim ger. Some ofthe older children injured or Hall in a Nov. 2 letter to the administra- killed in the accidents studied were not tor of the National Highway Traffic restrained or were improperly restrained Children’s Advocacy Center opens suburban satellite SafetyAdministration. with lap and shoulder belts. As a result, In a recommendation to the American they were too close to the air bag com- HAZEL CREST Responding to the vention Program, which streamlines the [ j Hospital Association, the safety board partment module and were struck in the need for supportto deal withchild abuse investigation process and helps prevent said hospitals with obstetrics units head and upper body by the air bag at its and neglect in the southern suburbs, the the inadvertent re-victimization of chil- should conduct a mail campaign warn- peak force, Hall explained. Chicago-LaRabida Children’s Advocacy dren during that process, explained a ing anyone who has given birth in the The safety board stressed, however, Center has opened a satellite center in LaRabida news release. The center plans past year about the dangers of placing a the good that air bags can do. Data from Hazel Crest, said a spokesperson for such initiatives as court advocacy, short- rear-facing child safety seat in the front the NHTSA show that air bags can LaRabida Children’s Hospital and term group therapy for young victims seat ofa vehicle with a passenger-side air reduce the chance of death in front-end Research Center. and support groups for nonoffending bag. In many of the accidents studied, crashes by20 percentto 40 percent. “Currently, 20 to 25 percent of parents. “The VSI program is only one children suffered skull fractures and Chicago-LaRabida Children’s Advocacy part of the process for victims of child Center clients are from southern Cook abuse or neglect and their families,” said County,” said Fred Nirde, director ofthe Neil Hochstadt, LaRabida’s vice presi- Meetings examine health of individuals, communities center. “The Hazel Crest satellite center dentofbehavioral science. will make it easier for victims and fami- In related news, the Department of CHICAGO Urban community nity should also be assessed. lies to receive the services they need Justice’s Office of Juvenile Justice and l[eaders of variou]s health care organiza- Sinai Health System, established last without having to travel far from their Delinquency Protection designated the tions gathered Oct. 25 at a series of year, is a West Side health care network home.” Midwest Regional Child Advocacy Cen- town hall meetings convened by Sinai that includes Mount Sinai Hospital One of the programs offered by the ter of LaRabida Children’s Hospital and Health System to focus on the needs of Medical Center, Schwab Rehabilitation new center is the Victim Sensitive Inter- Research Center as one of four regional the inner city. The series, called “Heal- Hospital and Care Network, Sinai cMhRilCdAadCvocacy centers nationwide. The ing Bodies, Building Lives,” was con- Medical Group and Sinai Community will help communities in 12 ducted at Mount Sinai Hospital Med- Institute. states identify issues they could face ical Center. while developing programs to curb child A discussion about the delivery of abuse. The child advocacy center will hweaasltlhedcabrye iEnduwnadredrsLearwvleodr,codmimruenctiotrieosf Top 20 reasons for outpatient visits ghrealmps,theidecnotmifmyunaintdielisnkesutpabwliitshh lporcoa-l the Center for Health Administration (Bypatientssurveyedinthe UnitedStates, 1993) resources, and train professionals and Studies at the University of Chicago. He community volunteers to work with asked the group to develop a report abused children and their families, a card listing criteria to assess community Numberof Percent news release said. needs. “Report cards are becoming Reasonforvisit visits distribution “Child abuse is a growing problem in more and more popular in the health All visits 62,534,000 100.0 not only the cities, but the suburbs and cmaeraesuirneddusgtetrsy,d”onhee.”said. “What gets Progressvisit 6,593,000 10.5 rcuhrialld aarbeuasseasmaweyll,b”e Nmiorrdee psariedv.al“eWnhtilien The report card should include med- Routine prenatal examination 3,900,000 6.2 large population centers, it happens ical information, said ISMS President- General medical examination 3,140,000 5.0 throughout our communities, and each weplaeetcetndeSeiadnndttorhaekndOiolsswcounst,shieoMnrD.ep,o“rFwtoihrnogexrpaaatmretpsilceoi,-f WPeolsltobpearbaytievxeamviisniattion 11,,339644,,000000 22..22 atrrereseaoaturtmchaeessyethchahaivtledcraaenn.dsiTtfrfheeernegMntthReCcnaApthaCeciirotfycfuetrro-s immunizations, sexually transmitted Stomach and abdominal pain, rent programs or facilitate the establish- diseases, tobacco and alcohol usage, cramps and spasm 1,121,000 1.8 ment ofprograms wherenone exist.” access to prenatal care, teen-age preg- Cough 1,119,000 1.8 In Illinois, for example, 328,000 cases nancy and the many different forms of of child abuse were reported in 1992 cancers.” Each of these areas profound- Skin rash 806,000 1.3 alone. Almost 50 percent of those ly affects the viability of a community, Fever 795,000 1.3 reports came from the less densely popu- and without those data, a community Earache or ear infection 728,000 1.2 lated regions of the state, the release would not have access to a system that Back symptoms 716,000 1.1 said. met its health care needs, she explained. “Throughout the United States, there Medication, other and unspecified 655,000 1.0 are notable successes in improving the Head cold 622,000 1.0 wsdhueeecancltmetshuassneatsdn,d”fCivEnsidaOtiadalioBtwfyeaSnoyinfnatcGioormeHbmeeuunainsllidpttahionen,Ssy,pstrtheaeosnmsid.e- CHDoeeupanrdseaesclshiienog,n,pnaoitnointhheerawdise stated 665201080,,,000000000 011...800 IaNi61sl0no9li6drp9n0ut6oJb2ihsul;bliMyMys(eih3dtcbe1hidhy2ec)iibtIgnlh7iaelew8ine2n(Ioe-IlAik1Slsvl6iSenyS5Nont4iuae1;stex0ec,S41et4M-apS-e8ttu6d0ei4i0tt0Mc-eh0ae7e)l8d7f2i0ViS-0crooIs,acltSliuMCewmtShSeye.oi.eccik8©aS,egteoNoycCf,,uooJmnpTIaydbwlnrleeuciirnlnagaotrhsi1yytss, “At SHS, we have learned thatthe health Other and unspecified diagnostic tests 500,000 0.8 postagepaidatChicago,ILandatadditionalmailing offices.PrintedintheU.S.A. of individuals is inextricably linked to Prophylactic inoculations 492,000 0.8 POSTMASTER:SendaddresschangestoIllinoisMedi- the well-being of their community. Jobs, cine,TwentyNorthMichiganAvenue,Suite700,Chica- economics, education, housing, safety Hypertension 480,000 0.8 gMoe,diIclilnineoiosff6ic0e60of2.anSyubasdcdrriebsesrsc:haPnlgeea,sweitnohtioflydmIalliilnionigs and the fundamental social infrastruc- Knee symptoms 479,000 0.8 labelifpossible. ture of a community are essential to its All other reasons 35,892,000 57.4 Subscription$12.00peryear,inadvance,postagepre- paidfortheUnitedStates,Cuba,PuertoRico,Philippine health and to its veryviability.” IslandsandMexico. $19.00 peryear forall foreign Other participants in the discussion countriesincludedintheUniversalPostalUnion.Cana- noted that the economic status, values Source:U.S.Dept,ofHealthandHumanServices,NationalCenterforHealthStatistics, d(a$:1.$3012b.y50m.ailU).,S.baccukrriesnstuessin$g1l.e50c.opiesavailableat$1.00 and educational systems in the commu- "MedicalBenefits,"Nov. 15, 1995 JANUARY 19 1996 ILLINOIS MEDICINE • 3 Watch Illinois Seminar helps residents negotiate, interview negotiate,” explained Schmiege, president of Med- Corrigan-Halpern PREPARATION: More options bring more challenges to new physicians, byjanice rosenberg Strategies Con- sulting Group in [ CHICAGO ] When asked how often Section seminar last fall answered with a ness Side ofMedicine” aims to help resi- Burr Ridge. “As they hear from recruiters, residents question: “Do you mean how many times dents enhance their business skills, a result, residents Andrew attending an ISMS Resident Physicians a day?” Today’s new doctors looking for including decision-making and negotia- sign poor con- post-residency practices are being courted tion, said David P. Schmiege, the pro- tracts where they by a variety of physician-recruitment ser- gram facilitator and the consultant who don’t understand Workshop lays the vices. In fact, some report offers in cities helped develop the program. “After the ramifications. rangingfromChicagotoTimbuktu. three to five years of clinical training, They focus on foundation for practice Although having a lot of choices is residents haven’t had much opportunity salary and bene- Schmiege exciting, it can complicate decision-mak- to develop business skills. When the time fits, but they Today, medicine is practiced in a ing. That’s one reason the program comes to consider contracts from poten- don’t think about future possibilities like dynamic climate that requires finan- “Paving the Way to Practice: The Busi- tial employers, they haven’t learned to (Continuedonpage 10) cial and managerial skills as well as clinical expertise. To help residents make sound decisions to launch BlueCross BlueShield AMemberoftheBlueCrossand their careers, ISMS’ Resident Physi- LrAT ofIllinois BlueShieldAssociation, cians Section offers the program AnAssociationofIndependent BlueCrossandBlueShieldPlans “Paving the Way to Practice: The Business Side of Medicine,” presented by David P. Schmiege, president ofMedStrategies Consulting Group. EPORT About 60 residents from around the state attended sessions on Oct. 28 and Nov. 4, 1995, and another is scheduled for Feb. 4 in Springfield. The day-long workshop is divid- ecrditiinctaloafsopuerctpaortfs,esetaabclhisahdidnrgesasimnegd-a for Illinois Physicians ical career. The first segment focuses on employment opportunities, advises residents on selecting a location and practice structure, and MEDICARE reviews practice options in areas such as occupational health. Specifi- cally, criteria are given for evaluating the options of solo practice, group practice, hospital affiliation Laboratory Tests Utilizing Automated Equipment and managed care entities like HMOs. In addition, this section provides practical information on Medicare covers the following twenty-two (22) common laboratory tests when such topics as group division of performed in groups or combinations on automated equipment. income and considerations in assess- ing the financial status ofa practice. The second section walks resi- Alanine aminotransferase (ALT, SGPT) Creatinine kinase (CK, CPIC) dents through each step ofthe inter- Albumin GaMMAGLUTAMYLTRANSFERASE(GGT) viewing process, from preparing a CV to evaluating an interview. It Alkaline phosphatase Glucose includes questions that candidates Aspartateaminotransferase (AST, SGOT) Lactate dehydrogenase are commonly asked and questions Bilirubin, direct Phosphorus they should consider asking Bilirubin, total Potassium prospective employers. Contract evaluation is the subject Calcium Protein, total addressed in the third part of the Carbon dioxide content Sodium program. Residents learn which Chloride Triglyceride provisions should be included in every employment or buy-in agree- Cholesterol Urea nitrogen (BUN) ment; how to find, evaluate and Creatinine Uric acid work with a health care consultant, attorney or accountant; and how to negotiateeffectively. Payment will now be made only for those tests in an automated profile that are medically The final segment covers finan- reasonable and necessary. Where some ofthe tests in a profile are covered, payment cannot cial topics such as budgets, life and exceed the amount that would have been paid if only the covered tests had been ordered. For disability insurance, investments, retirement plans and estate plan- example, the use of a 12-test profile to determine the blood glucose level in a proven case of ning. Because of the current eco- diabetes is unreasonable because the resultofa blood glucose test performed separately provides nomic climate, savings and loan the essential information. associations look closely at the loan applications of young physicians, who typically have a large debt Physicians are encouraged to limit their test ordering solely to those tests that are related to load, little business experience and specific symptoms and disease conditions. Medicare will pay only for tests that are medically no assets - but great potential. Sav- reasonable and necessary, and it will not pay for routine screening tests. ings institutions require specific information, which is outlined in the seminar. The workshop prepares residents to project an image of (Issue: 1/19/96-DEB) responsibility. For more information about the Feb. 4 workshop, residents may call (312) 782-1654 or (800) 782-ISMS, ext. 1241. Health CareServiceCorporation,aMutualLegal ReserveCompany (BlueCrossandBlueShieldofIllinois) JANUARY 19 1996 EDITORIAL VOLUME 8, NUMBER 1 JANUARY 19, 1996 common Resolving to use sense Illinois Medicine is publishedevery otherweek except the firstweek ofJanuary andJuly by the Illinois State Medical Society, 20 N. Michigan Ave., Suite 700, Chicago, IL 60602. Phone (312) 782-1654, (800)782-ISMS;fax(312)782-2023.Officehours:Mon.-Fri. 8:30a.m.-4:45p.m. ©Copyright 1996 bytheIllinoisStateMedicalSociety.Viewsandopinionsexpressed inIllinoisMedicine Based on comedians’ routines and Another resolution might be to help aproelincoytofnetcheessIalrliilnyoiesnSdtoartseeMdedbiyctahleSIolcliineotiys,SbtuattearMeediinctaelndSeodciteotyr.aiEsdeitiosrsiuaelssidnomendoitcnienceesosfariimlpyorretfalenccteoftfoictihael media coverage, you’d think every- patients make sense ofcontradictory sur- membership. one was making New Year’s reso- vey results or avoid overemphasizing Illinois State Medical Society lutions. But more than 60 percent of them. The benefits of drinking red wine Raymond E.Hoffmann,MMDD PRESIDENT Ainme1r9i9c6a,nasccwoornd’itngevteonantryAtMoAmasukrevety.hem hpaatvieentbseeanrewiidgneolryintgouttheed,prbouvtisoso“mien RonaldG.Welch, ChairmanoftheBoard In medicine, resolutions can be moderation.” Before Christmas, the AlexanderR.Lerner ExecutiveVicePresident opportunities for patients to make British Medical Association Journal Illinois Medicine Committee changes leading to a healthier lifestyle released survey results claiming that and for physicians to enhance the physi- wine has a “superior ability to kill ill- EdwardJ.Fesco, MD,Chairman cian-patient relationship through better ness-causing bacteria in food,” according EdmundDonoghueJr.,MD SilvanaMenendez,MD communication. Certainly, there are to the Boston Globe. The findings creat- RichardA.Geline,MD SandraF. Olson,MD always obstacles to communication - a ed a “media frenzy,” helping Europeans RaymondE.Hoffmann, MD JanisM.Orlowski,MD shortage of time, for starters. In addi- justify their love affair with wine. Do JaneL.Jackman, MD ScottReid,DO tion, some managed care plans are using your patients feel free to discuss such HaroldL.Jensen,MD ErloRoth,MD confidentiality clauses in contracts to studies with you, including their person- WilliamE.Kobler,MD SylviaEberle,Alliance prohibit doctors from talking to patients al application ofthe results? about proposed tests and treatments pri- A study reported in a December issue Illinois Medicine Staff or to plan authorization, reported the of JAMA maintained that a “strikingly Editor,LynnKoslowsky New York Times. A director at the Med- high percentage of patients treated at Writer,MaryNolan;Production/DesignManager,CarlaNolan ical Society of New Jersey said these two large public hospitals couldn’t read clauses “discourage physicians from or understand basic written medical DesktopPublishingSpecialist,ChristineVictor talking openly to patients about the need instructions.” The rate was particularly Advertising Information for specialty care and the role of man- high for patients over 60. If the study Sendalladvertisingorders,correspondenceandpaymentsto:IllinoisMedicine,20N.MichiganAve.,Suite aged care companies in limiting tests and results are representative, this is disturb- 700, Chicago, IL 60602. IllinoisMedicinewill be published everyotherTuesdayexceptthe firstweek of treatments.” ing news because itcoincides with trends JMaenduiacraylaSnocdieJtuyly.beAlidevcesoptyhemaudsvterbteisreemceenitvsedinfotuhresweeceoklsumprnisortotobeisfsrueomderseipreudt.abAlletshoouurgcehs,thIeSIMlSlindoiosesStnaotte But open communication is at the toward early patient discharge from hos- investigate the offers made and assumes no liabilityconcerningthem. ISMS reserves the rightto decline, heart of the physician-patient relation- pitals and expectations for greater withdrawormodifyadvertisementsatitsdiscretion. ship. And thankfully there are no restric- patient responsibility in health care. tions on counseling patients about Physicianscan help alleviate the situation AdvertisingGuidelines lifestyle changes they need to make. For by avoiding medical jargon and verbaliz- AdvertisementsinthisissuehavebeenreviewedtocomplywiththePrinciplesGoverningAdvertisinginIlli- noisMedicine. Acopyofthese principlesisavailableon request. The appearanceofadvertising in Illinois example, do you regularly discuss exer- ing theirinstructions, researchers said. MedicineisnotanISMSguaranteeorendorsementoftheproductorserviceortheclaimsmadefortheprod- cise with sedentary patients? Half of all When you get down to it, resolutions uctorservicebytheadvertiser. American adults get little or no physical are nothing more than the regular appli- Pharmaceutical Advertising Representative exercise, according to an epidemiologist cation ofcommon sense to solve a prob- LifetimeLearningInc.,JohnWright:(414)520-3409. at the University of Minnesota, as lem-not such a bad idea after all. reported in the New YorkTimes. PRESIDENT’S LETTER AMA How can the reinvent itself? Raymond E. Hoffmann, MD The recent AMA meeting was filled with important issues. tionalentities butarenowtryingto becomepolitical lobbyinggroups. While we were in Washington, D.C., the budget battle was The proposed AMA revamp would result in more than 650 dele- just warming up. I hope that by the time you read this, it will gates. There are only 535 people in Congress to run the entire Unit- be over and thegovernmentwill be back ontrack. ed States! AMA With this historic confrontation as a background, the is Another major concern is whether all of us could be represented struggling to become more representative of all physicians. This by multiple organizations. For instance, a young African-American would make the AMA more relevant when it seeks to speak for the female orthopedic surgeon in an HMO could be represented by as “house of medicine.” A major concern of legislators is that although many as eight different votes. Is that fair? In Congress each citizen is AMA the is the largest physician organization, its membership is com- represented by only three votes from three people, two senators and AMA posed of less than 50 percent of U.S. physicians. The is con- a representative. cerned because itcould speakwithmore authorityduringnegotiations Recently, organizations fighting for large increases in their dele- ifotherphysicians’ organizationswerenotexpressingdifferingviews. gations have gone to Washington and made separate agreements. Is How can that be done? How can the AMA make itself new in it fair to give more voice within the AMA to organizations that have these new times in this new year? A 200-member study group sent made its work harder, even ifthere is no requirement to stick to the The report the AMA’s House ofDelegates a reportcalled the “Study ofthe Fed- majoritydecision? eration,” which recommended sweeping changes in the way in So how do we solve this problem? Medicine needs to speak with advocated repre- which delegates and trustees are chosen. This whole process started one voice. We need to figure out how to iron out our differences with the conclusion that the AMA is best-positioned to make its inside ourown organization before we go publicwith issues. sentation based membership more inclusive. Over the years we have often heard that the AMA no longer The report advocated representation based on specialty, involve- stands for “my beliefs.” It is accused of being distant and of not on specialty, ment in managed care, gender, ethnic background and stage of understanding what the solo practicing physician in rural Illinois or HMO career in addition to the traditional proportional representation the physician in Chicago needs. involvement in from states. These more narrowly defined organizations now exist, Well, now is the time to tell the AMA. This debate is not over and most ofus belongto some ofthem. specific issues butover how issues in the futurewill be decided. managed care, Ofcourse, change creates problems. Those who have learned and Do you want to be known by membership in a national organi- succeeded under the current rules are suspicious of change. This zation- based only on geography-or are you now more inclined to gender, ethnic includes some state organizations and small specialty organizations consider yourself a member of a specialty group or a managed care that have worked togettheirmembers to join the AMA. organization? background and Those suspicions do not arise just from fear of losing influence. The AMA is trying to make sure it is relevant in the coming Some organizations are run by a few elite physicians such as years. You can help. Contact your AMA delegate or me through stage ofcareer. departmentchairmen. And otherorganizations werecreated aseduca- ISMS orwrite a letterto Illinois Medicine. Do itnow. Please! JANUARY 19 1996 ILLINOIS MEDICINE • 5 Commentary GUEST EDITORIAL ’Twas the night before Christmas, and here come some lawyers ... ByT. Evan Schaeffer Reprinted by permission: Tribune Media on previous Christmas mornings. Services According to one class-action petition, brought on behalf of all children living There was astonishing news this Decem- within the jurisdiction of New Jersey, ber about Santa Claus. High-placed Santa “failed to live up to the promise of sourcesreportthat lastmonth, Santa invit- the season” and “tortuously caused ed several ofthe nation’s top law firms to plaintiffs to experience headaches, stom- meet with him at the North Pole. Appar- ach cramps and vomiting when, on Dec. entlyatwit’send, Santa told theassembled 25, they didn’t find all they asked for lawyers that he’s facinga growingarrayof beneath the Christmas tree.” hliesgalyeparrolyblveimsiststhtaotAmmaeyrisclaonwcohriledvreenn.stHoep conTdheomungehdltehgiasl “esxopeurrtsgrhaapvese troorutn”dlays A painful look at how we die then served the lawyerscocoa and asked if meritless, judges everywhere are reluc- theycould help. tant to dismiss the lawsuits until Con- Although much of the story is still gress acts first. Caught in the middle, By Ellen Goodman vague, the North Pole moved to quell Santa plans to make use of a video sys- some of the speculation last week when tem that will record his dialogue with Copyright 1995, the Boston Globe tors did. Living wills didn’t help. There it took the unprecedented step ofholding the children who sit on his lap. In addi- Newspaper Co. Reprinted by permis- was too little talk, too late. Too many a news conference in Duluth. The details tion, he’ll ask obvious troublemakers sion. people died alone, attached to machines. provided to reporters paint a sorry pic- and their parents to sign a release form. The easy villains of the story would ture of the growing litigiousness of the Santa’s spokesman told the journalists The newspaper comes to my doorstep be the paternalistic doctors who remain American character, as well as the com- that he has abolished his longstanding this morning bearing its daily quota of convinced they know what’s best for the plications practice ofwith- obituaries. A teacher has died at 65. A patient even if the patient disagrees. caused by the holding presents costume designer at 81. A civic leader at There’s enough truth in that image to vast web of to naughty chil- 70. Acompany executive at 69. make Boston University ethicist George legal rules and dren. “In this The lives ofthese people are described Annas warn that “if dying patients want regulations day and age,” as ifthe death notice were a resume. The to retain some control over their dying that character- the spokesman causes of death - cancer, heart failure - process, they mustget out ofthe hospital ize American said, “it’s just are included as if disease itself were a ifthey are in and stay out ofthe hospital society. Santa’s too risky.” flaw in the human system that science ifthey are out.” spokesman High-placed has yetto fix. A more benign interpretation is that suggested that sources report What is missing from these pages - the culture of medicine - from school to this Christmas, that the lawyers what is always missing - are the descrip- training to practice - teaches doctors to it might be who met with tions of how they died. Was the teacher regard death only as defeat. Even when wiseto ponder Santa were ap- in pain or at peace? Did the executive dealing with the terminally ill, they talk what’s gone palled by what have a living will and a doctor who lis- about life and death decisions when they wrong. Hegave they learned. tened? Did the civic leader linger are really dealing with death and death sometroublingexamples: The formerly jolly St. Nick complained attached to a machine? Was the design- decisions. To Christmas aficionados, both that his insurance rates have quadrupled er’s death one she designed? But Dr. Lynn believes that the prob- young and old, it’s well known that San- and that he spends at least six weeks a I read these pages wondering what it lem runs deeper than doctors who don’t ta’s reindeer, having been specially bred year dealing with forms and other paper- would be like if we listed the way of listen. “This wasn’t a group of doctors to fly long distances in the air, are the work. “Nothing is simple anymore,” he death as well as the cause of death. dedicated to finding the last possible date animal of choice for the difficult job of said. In one instance, a group of Wouldthatmake a difference? on the tombstone. What we learned was pulling Santa’s sleigh. Nonetheless, it’s Louisiana cops, fearful of the rise in Last week, something remarkable that the conspiracy of silence about now official that Santa is under investi- domestic terrorism, forced him to submit happened. The newspapers in this coun- death was stronger than we expected, gation by American’s own Equal to a strip search before they would let try ran a story about a scientific un- and the force of habit was also stronger Employment Opportunity Commission, him cross the border into the state. breakthrough. A research project begun than we expected.” which is exploring a complaint by an “Humiliating,” Santa told the lawyers. with high hopes to test ways of making On a day-to-day basis, neither doctors Alaskan dog breeder that the job should When asked at the news conference death in the hospital more humane was nor patients were talking about what the be opened up to other four-legged crea- whether it wasn’t the lawyers themselves pronounced a failure, DOA. patients wanted. They were both follow- tures. The new sleigh-pullers would who were to blame for the country’s The flop was on Page 1, 20 years ing the cultural script, talking about the include not only dogs with previous sled- problems, Santa’s spokesman replied after Karen Ann Quinlan lapsed into a nextchemotherapy, the nextprocedure. pulling experience, but also moose, bear that his boss had considered, but then coma. It came after a whole generation They were patching, fixing, going and even muskrats. Understandably, rejected, this possibility. “You Americans of talk about high-tech dying and living from crisis to crisis without ever asking, Santa is uncertain howto respond. live in a democracy,” the spokesman wills and the rightto die. “Howcan I live well while dying?” In another development, Santa was said. “You all share the blame equally. When the Robert Wood Johnson “We are all involved in the dance of informed by the Environmental Protec- My advice is catch hold ofthe Christmas Foundation funded this eight-year study, silence,” believes Dr. Lynn. Even families tion Agency that he faces fines and possi- spirit and try to apply it all year long to there was a growing consensus among going through this painful process want- ble jail time for other legal transgres- your social interactions.” ethicists and doctors about how to ed one thing: “to pass the mirror test. sions. According to a letter he received Surprisingly, Santa is a big defenderof change the way ofdying. Ifdoctors really They want to be able to look at them- by certified mail, Santa is in violation of lawyers these days. According to were sure ofthe prognosis ofa patient, if selves when it’s all over and say, ‘I was a the Clean Water Actevery timethe flying sources, he laughed with delight when they knew what patients wanted and decent person.’” Close up, that “decen- reindeer relieve themselves over an one of the law firms visiting the North didn’t want, surely there would be less cy” is still defined as fighting death. But inland waterway. Although Santa Pole told him how he could pay for the pain, fewer “heroic measures” and more when you stand back from the mirror, as protested to the EPA that he rarely flies cost of legal representation. Here’s the care inthe hospital care ofthe dying. this study does, it’s a sorry reflection. over open water, the agency replied that idea. Since he owns the rights to his own So, the study’s project called Hospitals are not the only places itwould “shut down the entire works” if image, Santa can generate huge revenues SUPPORT - Study to Understand Prog- where we die. There are hospices and he didn’t institute an environmental by charging advertisers to use his like- noses and Preferences for Outcomes and homes. There are as well the “tender compliance program within 90 days. ness in their ads. By licensing his image, Risks of Treatments - placed nurses in mercies” ofDr. Kevorkian and the moral Then, unbelievably, there are the law- Santa will tap into a steady source of five teaching hospitals to facilitate these ambiguities ofdoctor-assisted suicide. suits. Although Santa has always had to income that he can use to pay his legal changes. But as Dr. Joanne Lynn, a co- But the majority of Americans end defend the occasional products liability counsel. director of the project says, “We did their lives in hospitals. As long as hospi- action, a new legal theory is now finding “Santa loved the idea,” his spokesman what everyone thought would work, and tals reject a humane role in helping peo- its way into American courtrooms. said. “He thinks it’sveryAmerican.” it didn’twork at all, noteven a quiver.” ple die, we are failing dismally as doc- Apparentlygoaded on bygreedy parents, Half of the patients still died in pain. tors, as friends and as fellow travelers a number of children are suing because T. Evan Schaeffer is an attorneyandfree- Huge gaps remained between what through what the psalmist calls “the val- they weren’t satisfied with what they got lance writerfrom St. Louis. patients said they wanted and what doc- ley ofthe shadow ofdeath.” 6* ILLINOIS MEDICINE JANUARY 19 1996 Students, residency programs must examine each other Pediatrics, however, is experiencing physician shortages, a problem that presents tremendous opportunities for stu- SEMINAR: Residents and program directors share interview tips, bymarynolan dents interested in that field. “There are a lot of medical pediatric [ OAK BROOK ] Making the right represented various specialties. be happy.” He noted that students must programs surfacing at hospitals. You match is the whole point of interviewing “[Interviewing] is really a matching put their best foot forward while being need to know about them,” said Robert medical students for residency programs, process where we try to weed out those honest with the interviewer about their Oliver, MD, a resident physician in the but both sides need to check each other [students] who would not fit into our interest in the program. “Believe me, Department of Medicine and Pediatrics out thoroughly, according to speakers at program,” said Warren Wallace, MD, none of us will be happy in August ifthe at Southern Illinois University’s School of the ISMS Medical Student Section’s director ofpost-graduate education at the program is notwhatyouexpected.” Medicine. He suggested that students ninth annual “Preparing for Residency Department of Medicine at Northwest- The resident physicians explained to make a list of the programs they are Interviews” seminar held last fall in Oak ern University’s McGaw Medical Center students the potential opportunities and interested in, including descriptions of Brook. Students heard from resident in Chicago. “It is critical thatwe commu- pitfalls ofcertain specialty programs. For the physical surroundings of those insti- physicians who shared their interview nicate to our applicants the kind of pro- example, anesthesiology is facing diffi- tutions. “This is important because experiences and program directors who gram we have so [residents selected] can culty because the market is saturated. you’re going to be there for years and you need to be happy where you’re at,” Dr. Oliver said. During the interview, “you must ask questions - hard questions - about the program that you’re interested in,” advised Mitchell Glaser, MD, a psychia- try resident physician at the University of AUDIO-DIGEST. Chicago Hospitals and a resident member of AMA’s Council on Medical Ser- vice. He suggested asking about the pro- THE SHORTEST DISTANCE DETWEEN gram’s goal for residents and the resident’s role in caring forthe patient. FOUR POINTS. “You must be honest [in everything you say] and be prepared to sell yourself in the first 60 seconds,” Dr. Glaser said. “[Program directors] are looking for someone whowill be a leader.” Interviewing is “a two-way interac- tion where you’re trying to learn as much as you can about a program and the program is trying to learn as much about you,” said Samuel Gotoff, MD, chairman of the pediatrics department at Rush-Presbyterian-St. Luke’s Medical Center in Chicago. “Remember,” he said, “medical schools provide information about you, and you get letters of recommendation, so the program director is learning something about you from paper.” Most important, the interview is a way for students to distinguish themselves from what’s on that paper, he added. Many resource materials are available to help students determine which hospital program best meets their needs, said Everyone agrees that it’s important to stay current. But with so Michael Rainey, PhD, associate dean of student affairs at Loyola University’s many different priorities, who has the time? Stritch School of Medicine at the May- wood campus. For example, information on U.S. residency programs and institu- Audio-Digestsavesyouthetime and expense oftravelingto meetings. Everyyear,weexhaustively tions is available through the AMA’s Fel- cover morethan 350 majormeetings,seminarsand postgraduatecourses in 13 specialties.Then, lowship and Residency Electronic Inter- becausea 1-hourtalkmaycontain only30 mi—nutes oftruesubstance,wepainstakinglyeditso that actiTvheeDasteambiansaer’AscckeesysnSoytseteamd.dress was youhearonlythe“meat”ofthepresentation in lesstime,with no lossofimportantcontent. given by Sandra Olson, MD, ISMS’ pres- Perhapsbestofall,youstaycurrentonYOUR OWN TIME. YoulistenwhenYOU want—athome, iSdheentt-oelledctstaunddenatsnetuhreolporgaicstticien oCfhimceadgio.- intheofficebetweenpatients,whileyou’redriving,whileyou’reexercising. It’s uptoyou. cine is changing by leaps and bounds, and those changes will continue at a rapid pace for years. “You, as doctors, For more information and a FREE SAMPLE CASSETTE, call need to seize and keep the reins of control ofmedical practice for the patient. It 1-800-423-2308 now. And start closing the distance today. won’t be easy, but this revolution is just beginning. I think physicians are just starting to realize their potential power in this [managed care] arena.” Dr. Olson centered her address on the “seven Cs” of medical care in the 21st century: change, control, competition, culture, communication, community and caring. Using the metaphor of “sailing Audio-Digest Foundation® those seven Cs,” she said: “I envision these waters as often turbulent and AllmedicalcoursesareplannedandproducedinaccordancewiththeAccreditationCouncilforContinuingMedicalEducation (ACCME)Essentials.ProgramtapesarepresentedbyAudio-DigestFoundation,asubsidiaryoftheCaliforniaMedicalAssociation. rough, especially for those unprepared TheCaliforniaMedicalAssociationisaccreditedbytheACCMEtosponsorcontinuingmedicaleducationforphysicians. for the journey. But, from what I have EachAudio-Digestprogramisapprovedforupto2hoursofCategoryIcredit,andmaybeappliedtowardthe seen, I am confidentthat the medical stu- AmericanMedicalAssociation’sPhysician’sRecognitionAwardandadditionalcreditwheredesignatedbyqualifiedboardsandassociations, dents and residents of today are better includingbeingacceptablefor96hoursannuallyofprescribedcreditbytheAmericanAcademyofFamilyPhysicians. 0641 equipped than we were as they get ready topractice aftertheyear2000.” JANUARY 19 1996 ILLINOIS MEDICINE • 7 Watch for coverage of how to close a practice Case in Point uesto ignore your advice.” Emmons explained that the Factual records help prove contributory fault phheysoircisahne mmuasdte daoncu“emxetnrtaortdhia-t nary effort” to warn the patient about the possible results of BYRICKPASZKIET ered her baby in April 1993. The points these cases make: ments than the patient,” said failure to follow the physician’s Pap smears during and after the Both cases demonstrate the Bill Anderson, a partner in the advice. When dealing with patient non- pregnancy were normal, so the need to keep a strong factual Chicago law firm Lord, Bissell “In short, physicians have to compliance, physicians should physician decided that a biopsy record to prove a patient’s con- & Brook. “Contributory fault show that they tried their best,” make sure they accurately docu- was unnecessary. However, a tributory fault. has to be based on direct and Emmons explained. “In a case ment specific related evidence. Pap smear performed in April “In contributory fault, you specific records. Otherwise, you of contributory fault, the physi- This factual record is vital to 1994 was again a class 3. A have to prove that the patient is risk alienating the jury by blam- cian cannot seem aloof or unre- prove com- biopsy was finally performed, more than 50 percent responsi- ing the patient. The first case sponsive.” parative or revealing cervical cancer that ble for the medical outcome,” clearly illustrates that the The physician’s first obliga- contribu- had spread throughout the said attorney Keith Emmons, a patient was given the necessary tion is to make sure that the tory fault, patient’s uterus. Further medical principal in the Champaign law knowledge about her condition noncompliant patient under- which is treatment was unsuccessful, and firm Dobbins, Fraker, Tennant, and that she knew the conse- stands the severity of his or her defined as the patient died of cervical can- Joy & Perlstein. “This proof quences of failing to follow the medical condition, said Melvin noncompli- cer inJune 1995. depends on accurate records doctor’s advice. Gerbie,MD, a Chicago Ob/Gyn. ance that is The patient’s estate sued the that clearly indicate that the “The physician in the second “By showing the patient a more than 50 percent responsi- physician for failing to diagnose patient deviated from a doctor’s case had inadequate documen- videotape on cervical cancer, the ble for a poor medical outcome. cervical cancer. After the jury advice.You have to show what tation,” Anderson continued. doctor in the first case took that Case #1 concluded that the patient was the patient did or did not do.” “Once the patient refused to extra step to protect himself as more than 50 percent responsi- The enactment of H.B. 20 come in for another consulta- well as the patient. The Ameri- The case in brief: In February ble for the outcome, the verdict has significantly changed how tion, the doctor, knowing the can College of Obstetricians 1986, an Ob/Gyn read a was returned in favor of the juries are instructed regarding seriousness of the case, should and Gynecologists has pro- patient’s Pap smear as a class 3. physician. the contributory negligence stan- have recorded her refusal in the duced a series of such videos Ttohetrpehaytsihceiranfoursecedrvciacuatleriinzfaltaimo-n Case #2 d“aTrhde isnamIlelinloaiws,isEmbamsoicnasllysasitidl.l pcearttiiefnite’dslecthtaerrtthaantdrespeenattehderhias tchoantfraorneteadgrweiatthhselupchtonodnocctoomr-s mation and told her to return The case in brief: A 38-year-old in effect. However, the jury is no warnings.” pliantpatients.” foranother examination in three patient discovered a lump in her longer instructed that a plaintiff “You need some type of “The doctor has limited con- mdiodntnhost. rTehteurnpattioentth,ehOobwe/vGeyrn, rOibg/htGybnre.astThaendphcyonssiuclitaend dhee-r f[awuhlot icsamnonroet]rtehcaonve5r0 pdearmcaegnetsa.t rmeecdoircdaltoaddveimcoenswtarsatgeivtehnattoyotuhre tDrro.l oGveerrbitehespaaitdi.ent“’sYoaucticoanns’,”t until fiveyears later. Once again, scribed the abnormality as a The jury renders its verdict, but patient, and that the patient force a patient to come in or tclhaessPa3pcesllmuelaarrarteyspuilatscornesviesatleendt a“fnudllrneescsomomfetnhdeerdigahtmbarmemasot-” jthuedgcmoeunrtt mifutshtetjaukrey afwinadys tthhee uinngd,e”rsctoonocdurwrheadtRyoboeurtweLraePastaay,- hdaoevse haatveestadgorneea.tBduetalaodfoccotno-r wdyistphlaslioaw-ofttohemcoedrveirxa.te-grade gmroagmr.aFmouwrasdaypserlfatoerr,mead,maamn-d patiWeintthiosu5t0rpeelricaeblnetadtocfauumlet.n”ta- M“WDh,enanaOpabt/ieGnytnreifnuseEsvatnosltiostne.n Ttrhoilsovmeeratnhse ptahtaitente’vserryecotredsst., Although the physician rec- the resultswere negative. tion, the determination of to your advice or fails to have a every appointment missed and ommended an immediate diag- Nevertheless, the physician patient negligence may be test done, the doctor has to every patient discussion should nostic biopsy, the patient did not told the patient to return for a reduced to the word of the respond in a prompt and serious be carefully noted in the return to see the physician until follow-up examination in two physician against that of the manner. This means sending a patient’s chart.” early 1992, three months later. weeks, when she completed her patient. That can be a problem certified letter that tells the At that time, the physician menstrual cycle. However, the for doctors. “Physicians are pre- patient in bold language that “Case in Point” uses hypotheti- advised conization rather than a physician failed to schedule an sumed by juries to know more you are not responsible for his cal case history to illustrate punch biopsy, since the patient appointment for the patient. about medical issues and treat- or her case if the patient contin- loss-prevention maxims. had previously been treated with When his nurse called the cauterization. The patient, who patient about returning for a was trying to become pregnant, follow-up examination, the refused the procedure after the patient refused to come in. The MALPRACTICE ROUNDUP physician told her that it would physician then spoke directly to delay her attempted pregnancy the patient, explaining the by at leastsix months. importance of another exami- Beginning in fall 1991, the nation. Once again, the patient Physician obtained informed consent for laser therapy physician advised the patient refused to see the doctor. These about the seriousness ofher Pap conversations were never docu- A California jury found that a general surgeon had fully informed the parents of a 4-year-old stmweoarocrceassulitosnss,evetrhael pthimyessi.ciOann menStiexdmionntthhespaltaiteern,t’tshfeilep.atient p1a9t9i5enitssrueegaorfdMiengditchaelpMoatlenptriaacltirciseksLaawnd&coSmtprlaitecgayt.ions of laser therapy, according to the August recommended a biopsy, but the noticed a change in the nipple In Uriarte vs. Navas, the patient’s parents took her to the physician for treatment ofwart-like patient refused. The Ob/Gyn of her right breast. She saw lesions on her neck. The physician performed laser therapy, after which the child developed a documented those refusals in another gynecologist, who large keloid scar. The parents alleged the physician failed to obtain proper informed consent and the patient’s chart and recorded referred her to a surgeon. A to warn them of the potential risks and complications of the procedure. They also claimed the the fact that he showed her a biopsy revealed breast cancer, physician’s treatment was substandard because it was administered to a Hispanic patient, who videotape on cervical cancer. and the surgeon performed a was more likely to develop keloid scarring than a lighter-skinned individual would have been. The physician also sent her a modified radical mastectomy. However, the physician’s records showed he had discussed treatment alternatives with the parents certified letter underscoring the The patient sued the first and that he had informed them aboutpossible scarring. importance ofhaving a biopsy. Ob/Gyn for failing to diagnose The ruling confirmed that laser therapy was an appropriate treatment for the patient’s condi- The patient became pregnant her breast cancer. The case was tion, according to the article. in September 1992 and deliv- settled in favor ofthe plaintiff. 8* ILLINOIS MEDICINE MEDICAL ESSAYS t isn’t every day you find a book that examines the cosmic signifi- Icance of life through essays on dissection practices in 17th century Bologna or Aristotle’s explanation .of semen. Nevertheless, such a book has been written by pathologist F. Gonzalez-Crussi, MD. What may be truly unusual for this kind of esoteric work is that it hasn’t been relegated to obscurity: Last fall it received a glowing review in the New YorkTimes. “One reason I like to write essays is the freedom that the form gives,” Dr. Gonza- lez-Crussi said. “If I decide to write about mummies, it doesn’t mean I’m going to have to confine myself to ancient Egypt. You start writing with that, and you can wander off and write about anything as long as you do it with some measure of credibility and you come back to the original theme without appearing to be too rambling. Nonetheless, it gives you suffi- cient freedom that I don’t exaggerate when I say you can really talk about anything thatyou want.” The book, “Suspended Animation: Six Essays on the Preservation of Bodily Parts,” is the physician’s sixth published literary work. Dr. Gonzalez-Crussi began writing in the early 1980s, drawing on his work as a pathologist for inspiration and dipping into his personal experience to illustrate his ideas. You wouldn’t have anticipated a literary career based on his background, however. Dr. Gonzalez-Crussi was born in Mexico City to a family of “limited means.” After finishing medical school in Mexico, he completed a residency in pathology at the University of Florida. He worked as a pediatric pathologist in Canada until 1978, when he assumed his current posi- tion as head ofthe department ofpatholo- gy at Children’s Memorial Hospital in Chicago. In discussing his career choice, Dr. Gon- zalez-Crussi looks critically at the paths that brought him to pathology. “It’s often difficult for a person to say why he chose one thing over the other. Some say I must be obsessed with death to have chosen pathology, butI don’tthink that’s true.” Instead, the choice grew out of more prosaic circumstances. Two medical Medicine can be both art and science. school professors who became Dr. Gonza- lez-Crussi’s role models were pathologists. He described one as European, distin- By Janice Rosenberg guished and erudite, and the other as dynamic, young and handsome. “As a young student I didn’t see such shining ILLINOIS MEDICINE • 9 MEDICAL ESSAYS examples inother specialties,” he said. to do it because itwas a personal quest.” Then there was pragmatism. Dr. Gonzalez-Crussi Like his choice of specialty, his choice of subject considered ophthalmology, but he worried that accep- material was practical. Hoping to avoid painful rejec- tance into any surgical residency program might be tion letters, he looked for a way to make his writing more difficult because of his foreign background and different by drawing on experiences that were not the heavy competition for relatively few slots. Pathol- common to mostpeople. ogy residencies were available, so Dr. Gonzalez-Crussi “So even though it was a little lugubrious to talk signed on. about cutting up dead bodies, I think I have demon- “I think my personality was probably not strated that the subject can be approached fit for my becoming a surgeon,” he said. “I elegantly and that it is one that is worth see that now. Surgeons have to have a bold- reading about,” Dr. Gonzalez-Crussi said. ness and an ability to make lightning deci- His first books, “Notes of an Anatomist” sions that I lack. I like to take one thing and and “Three Forms of Sudden Death,” grew look at it from all sides.” out of professional interests. Then, to show Second, he wanted to be able to write-at that he could also write about subjects out- that stage of his career, he was interested in side his field, he wrote “On the Nature of writing textbook chapters and journal arti- Things Erotic” and “The Five Senses.” Of cles. He postponed taking up a more literary the former he joked, “That shows I can style until he wasnearly 50 years old. write about things for which one does not That postponement stemmed in part from have to be dead.” his uncertainty about his ability to express After writing “The Day of the Dead,” himself in English. In addition, the study of based on his Mexicanchildhood, he returned pathology absorbed him, leaving him little to his original subject matter in “Suspended time for the in-depth reading and research he Animation.” This most recent book was knewwould be required for the kind ofliter- partly inspired by photographer Rosamond arywritinghewished to pursue. Purcell, whose photographs accompany the “Sometimes I think I should have written when I text, and partly suggested by his publishers, who was younger and had another view of life,” he said. “I thought his original subjectwould respond to the pub- probably would have accumulated more prestige as a lic’scurrentinterestin death and dying. writer. After all, thatwas one thingthatIwanted to do, Dr. Gonzalez-Crussi said he views his audience as to become awriter. Buton the otherhand, thenIwould the general literate reading public. He does not write not have done what I did in the medical profession and specifically for physicians, nor does he believe they advancedtothe stagewhereIwantedto advance.” necessarily make the best readers. “Their responsibili- Eventually the time was right. “I thought that ifI ty is so great that they see the time they are investing waited to do what I always wanted to do until after in something else as time away from their becoming my retirement, I might not have the energy or would more proficient in takingcare ofpatients,” he said. be more easily discouraged,” he said. “I decided I had (Continuedonpage 10) munity, intellectuals and the inevitable idle and rich snobs, apart from medical students, gathered in the amphitheater. This motley crowd generated no Excerpt from “Suspended Animation: Six Essays small commotion with gossip, bumptiousness, and on the Preservation of Bodily Parts,” copyright self-display. Liveried lackeys appeared who circulat- ©1995 by F. Gonzalez-C&russi, reprinted by permis- ed amidst the attendees distributing bouquets and sion ofHarcourtBrace Company. oranges to the ladies, that “the perfume of the ones and the sweet aromas of the others” assist them in n 1405 the University of Bologna allowed up to brooking the unpleasantness of the emanations Itwenty students at the dissection ofa male corpse, wafting to their noses from the opened cadaver. and uptothirtyata female’s. In the followingcen- Members of the aristocracy received sticks smeared tury the demand became so great that amphitheaters with aromatic resins, which were to be burned dur- had to be builtin ordertoaccommodate theaudience. ing the performance as one more expedient against In Leiden, the apse of a church, of the former Falie revolting odors. In Bologna, the front seats were Baginhof, became the Theatrum Anatomicum that reserved for important officers, the prior, the coun- functioned from 1593 to 1773. InPadua, atthePalaz- selors and the electors. zo del Bo, the magnificent anatomical amphitheater The Bolognese amphitheater was magnificently with its concentric oval tiers, was built in 1594 and decorated for the occasion: the walls were hungwith saw the like of Galileo and Morgagni deliver lectures. damask, and two large torches, placed respectively The superb Bolognese amphitheater in the Archigin- at the head and feet of the cadaver, illuminated the nasioisanotherexample. working area. A crimson-gowned professor then Dissections were public and were widely adver- appeared, ceremoniously followed by his attendants, tised days ahead. In Bologna, notices were posted and silence descended upon the amphitheater. The on columns of the Archiginnasio, in Latin, which prior (whose prerogative it was to interrupt the was the language of the lessons. In Leiden, since demonstration at any time by clapping his hands) anatomical dissection took place in a church, the gave the ceremonial order to begin. The professor tolling of a bell summoned the spectators. In Paris, used all the ornate erudition of which he was capa- the streets adjoining the School of Medicine were ble to review, in flawless academese, the work ofhis decorated with garlands, flowers and festoons. Suc- predecessors; he would then lay out the chief points cessful physicians, prominent members of the com- ofthedemonstrationthatwas aboutto unfold. 10 ILLINOIS MEDICINE JANUARY 19 1996 * A literary look The New York Times book review Seminar helps nication skills in their evaluations, probably best sums up the appeal of Dr. Schmiege helps residents verbalize what (Continuedfrompage 9) Gonzalez-Crussi’s topic and his latest (Continuedfrompage3) theywant in a practice situation. work: “Death for us is what sex was for That is particularly important when “But because what I write is inspired the Victorians: something that fascinates salary escalations and contract residents interview with private practices, by what a segment ofdoctors do, I think and frightens us, an inevitability that we renewals.” he said. Although recruiters for large it would be enjoyed especially by physi- do not speak of, a scandal that makes a In the last year of their training pro- medical systems may focus on residents’ cians,” he explained. “And there are mockery of our pretensions to grandeur, grams, residents begin being courted by clinical qualifications and training back- doctors who are avid readers. Even med- dignity, transcendence. Dr. Gonzalez- recruiters- a relatively new phenomenon, ground, private practice physicians may ical students have asked me to sign the Crussi has delivered a missive that, said Mary L. Agnello, who also spoke at want someone who shares their medical book or give them advice. I’ve been though the envelope maygive offa whiff the program. Weeding through all the philosophy and will feel comfortable in invited by medical societies to speak, and of formalin, is in its essence a love letter material they receive is not easy for resi- theircommunity. colleagues have written reviews of my to life, in all its strangeness, beauty and dents in the midst of busy, stressful train- books in medical journals.” mystery.” ing. “Twelve years ago, when I started RESIDENTS SHOULD ALSO PREPARE to ask working in this field, physicians were questions. Schmiege readies residents for [still] going into private practice and had upcoming interviews by supplying them their own small businesses, so recruitment with 25 to 30 questions they should ask wasn’tan issue,” explainedAgnello, presi- potential employers. And they should n January 1995, a play based on Dr. Gonzalez-Crussi’s personal essays dent of Staff Development Corp. in ask them at the first interview to elimi- Iwas presented at Chicago’s Live Bait Theater. Adapted by the theater’s Brookfield, Wis. “In today’s environment, nate practices that aren’t a good fit, he artistic director, Sharon Evans, the production used a multimedia physicians have a different relationship said. approach that included puppetry, sculpture and film. with their careers. Now, more than ever, Ask how many physicians have left “If the subject matter was death, we wanted to be extremely animated on [they] will beemployees.” the practice in the pastthree to five years, stage as a counterpoint,” Evans said. “The set was an abstract representation Change has become the norm, she how many physicians on staff are board- told the group. “The era ofestablishing a certified and whether any have had mal- ofa cadaver, and all theactiontook place insidethe body.” practice and staying in one place for practice problems, Schmiege advised. The playwas well-received bycritics and drew a very strong response from themedical community, Evans said. One nightthe housewas soldouttomed- your whole career is pretty much history. Residents should also inquire about the ical students from Loyola University. After the play, the students participated Statistics show that 75 percent of you clinical styles of the other physicians in in a discussion withDr. Gonzalez-Crussi. will change your practice within five the practice aswell astheir lifestyles. Despite his initial skepticism aboutturninghis essays into theater, Dr. Gon- years and that you will change it a total “Find out how the practice is address- zalez-Crussi enjoyed the play, although he said he found it strange to watch ofthreetimes before you retire.” ing health care reform,” Schmiege said. an actorwearing one ofhis own labcoats. In addition to helping residents nego- “Are they approaching it in a reactive or “One thing that’s interesting in the business of writing, you never know tiate contracts, the seminar teaches them proactive stance? Are they doing nothing when someone might want to do something with your work,” Dr. Gonzalez- interviewing strategies. For example, res- because Clinton’s plan fizzled, or have Crussi said. “To me that’s very rewarding and different from medical writing. idents can role-play responding to ques- they just invested $35,000 in a computer tions potential employers will probably system because they know that they’ll In six or seven years, the textbooks I’ve written are obsolete, but there’s a chance thatyears from now, people might still enjoy readingmyessays.” ask, said Schmiege, a participant in the need a way of capturing data if they’re V J Society’s Consultant Referral Network. goingtocompete in theyearstocome?”i Because employers will consider commu- A CREATE MEDICAL BREAKTHROUGH. 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