Wisconsin Medical Journal

948 Pages·1996·82.1 MB·English

by  State Medical Society of Wisconsin

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Wisconsin Medical Journal
TheWisconsinMedicaljournal(ISSN0043-6542)istheofficialpublicationoftheStateMedicalSocietyofWisconsinandisdevotedtotheinterests
ofthemedicalprofessionandhealthcareinWisconsin.Themanagingeditorandeditorareresponsibleforoverseeingtheproduction,business
operationandcontentsofthejournal.Theeditorialboard,chairedbythemedicaleditor,solicitsandscreensallscientific,specialandsoundings
articles;itdoesnotscreensocioeconomicororganizationalarticles.Thechairprovidesleadership fortheeditorialassociatesandcommentson
botheditorialsandletterstotheeditor.Althoughletterstotheeditorarereviewedbythemedicaleditor,allsignedexpressionsofopinionbelong
totheauthor(s)forwhichneithertheWM/northeSMStakeresponsibility.TheWMJisindexedinIndexMedicus,HospitalLiteratureIndexand
CambridgeScientificAbstracts.
ThomasC. Meyer,MD,Madison Staff year single copies, $3 each. Previous years
MedicalEditor Betty-Lou Pellicore, Madison single copies, when available, $4 each. For-
Director,Communications eignsubscriptions,$40peryear.
Editorial Board ShariHamilton,Madison
ThomasC. Meyer,MD,Madison ManagingEditor SecondclasspostagepaidatMadison,Wise.
Chair
CherylMcCollum,Madison
SusanF. Behrens,MD,Beloit ContributingEditor Published monthly
JCKMehaefarsfrtraleiveynasHnD.C.K.uLHCtaoatmfynof,vnmeMtar,D,n,,MMDMDM,Di,l,WMwaaMaudiusilkswaeoauenukee VLiyDPcnrekniosediLug.BcnjMtoAeirsyogsenoir,sA,tsMasManiadtsditiasnsotonn Abadercgrecese3psp,rto1aal9vnl1ic7dce.eofdArourrfteomhrsaopiirnolinSizdenecegdtnaictAoesunpg1teu1ocs0i3att,lheA7r,catWt1ei9os1of8cf.OopcnoAtssdiot-n--
DonaldS.Schuster,MD,Madison MarthaGaie Medical Journal, PO Box 1109, Madison, WI
BenjaminC.Wedro,MD,LaCrosse
CommunicationsIntern 53701.Streetaddress:330E.Lakeside.
VictorS.Falk,MD,Edgerton
MedicalEditorEmeritus Telephone
Postmaster
608-257-6781 ortoll-free 1-800-362-9080
Editorial Associates Send address changes to: Wisconsin Medical
RussellF. Lewis,MD,Madison Advertising Journal,POBox 1109, Madison,WI53701.
JohnP.Mullooly,MD,Milwaukee Advertisinginformationappearsintheclas-
KennethI.Gold,MD, Beloit sifiedsectionatthebackoftheJournal.Fora ISSN0043-6542
JohnD.Wegenke,MD,Madison rate card or sample issue, please call 1-800- Established 1903
MaxwellH.Weingarten,MD,Milwaukee 362-9080.
CharlesW.Schauberger,MD,LaCrosse Copyright1995
Subscription rates
Members,$12.50peryear(includedinmem- StateMedicalSocietyofWisconsin
bership dues); non-members, $35. Current
Createdby theTerritorial Legislature in 1841 and now representing nearly8,500 memberphysicians, theSociety's purpose is to "advancethe
scienceandartofmedicineandthehealthofthepeopleofWisconsin;ensurethatphysiciansareequippedtodealeffectivelywiththeeconomic
andpoliticalaspectsofpractice;andserveasthepatientandphysicianadvocatetogovernmentandotherrelevantpublics."Themajoractivities
oftheSocietyconcernmedicaleducation,peerreview, legislation,communityhealtheducation,scientificaffairs,socioeconomics,healthplan-
ning,servicetophysicians,operationoftheCharitable,EducationalandScientificFoundation,andpublicationoftheWisconsinMedicalJournal.
OfficialsoftheSociety District 1 District4
MarciaJ.S. Richards,MD,Milwaukee Clarence P.Chou,MD,Mequon RobertJ.Jaeger,MD,StevensPoint
President TimothyG.McAvoy,MD,Waukesha JamesR.Keuer, MD, Minocqua
RichardH. Ulmer,MD,Marshfield MarvinG.Parker,MD,Racine RobertE. Phillips,MD,Marshfield
PresidentElect JohnE.Ridley, III,MD,Milwaukee
RichardG.Roberts,MD,Madison JayF.Schamberg,MD,WestAllis District5
PastPresident GeorgeR.Schneider,MD,WestAllis TerryL. Hankey,MD,Waupaca
ThomasL.Adams,CAE,Madison FrankH.Urban,MD,Brookfield Harry Zemel,MD, Fond duLac
J.
ExecutiveVicePresident RobertF.Purtell,Jr,MD,Milwaukee KevinF.Quinn,MD,Neenah
HarryJ.Zemel,MD,FondduLac CassandraP.Welch,MD,Milwaukee
Treasurer RaymondC.Zastrow,MD,Milwaukee District6
SandraL.Osborn,MD,Verona David Matteucci,MD,Kenosha David Deubler,MD,Kiel
J. J.
Speaker StephenD. Hathway,MD,GreenBay
MichaelC. Reineck,MD,WestBend District2 AnthonyR. Mars,MD,Marinette
ViceSpeaker AndrewB.Crummy,Jr,MD,Madison
CyrilM. Hetsko,MD,Madison District7
Board ofDirectors JerryM.Ingalls,MD, Monroe CharlesV. Ihle,MD,EauClaire
RaymondC.Zastrow,MD,Milwaukee AyazM.Samadani,MD,BeaverDam DouglasM. DeLong,MD, Ladysmith
PaulA.Wertsch,MD,Madison
Chair
MarkH.Andrew,MD,Viroqua BradleyL.Manning,MD,Madison District8
ViceChair RobertL.Sellers,MD,Superior
District3
MarkH.Andrew,MD,Viroqua gr
- ’
JackM.Lockhart,MD, LaCrosse olLlGE OF PHYSICIAN.
Or PHILADELPHIA
JAN 2 2 3896
Contents
January 1996 Vol. 95 No. 1
Opinions
5 President'spage
Carpe Diem
byMarciaJ. S. Richards,MD,Milwaukee
7 EVP report: Theviewfrom here
Guiding the wanderers
byThomasL.Adams,CAE,Madison
8 Guest editorial
Understanding where we are, where we want tobe, and how to get there
byJohn Frey,MD,Madison
J.
10 Letters to theeditor
The physician-assisted suicide debate
byJosephR Gibes,MD,Darlington
11 Bedside teaching
byRodSorensen,DO,Marshfield
12 Hearsay
Jammin'withthejournals
Focus on family practice
13 Family practice residency training capacity in Wisconsin:
current status and future projections
byWilham Hueston,MD,andRalphSuechting,MA,EauClaireandMadison
J.
17 Graduates comment on issues related to the decline ofWisconsin family physicians
providing maternity care
byNickTurkal,MD,andCarrolChristman,MA,MilwaukeeandMadison
22 Acurriculum in managed care for family medicine residents
byLorenA. Leshan,MD,Milwaukee
Public health
27 Over-the-counter sales of cigarettes to children:
results ofcompliance checks in Wisconsin, 1992-1995
byMaryGothard,JohnFox,MD,ThemisFloresdePierquet,CindyMusial,andRichardYoast,PhD,
Madison
WAPC
30 Position Statement
Human Immunodeficiency Virus (HIV) education and testing in the perinatal period
Contents
Socioeconomic
37 Oneofa kind
Combining sports medicine, rehabilitation and family clinical care makes physical
UW
and fiscal sense for Clinics
byMichaelMuckian
42 A wordfrom WIPRO
Warfarin encouraged for stroke prevention in atrial fibrillation
byJayA. Gold, MD,JD, MPH, Madison
44 CD Rom review
Clinical Reference Software—Patient Handouts
byR.ZorbaPaster,MD,Oregon
46 Videoconferencing
Technology in medicine
by Douglas Turecek, Management Information Systems director
47 Tenants insurance LIBRARY 0
bvMichaelJ. Dolan,CLU,ChFC,Madison JQl I F(2jZ nr rn
Organizational
2 2 1996
49 Physicians keep medical practice in the family
byCherylMcCollum, WMJcontributingeditor
^
52 Family practice: the call for more generalists continues
byMarthaGaie,SMScommunicationsintern
54 ADA is changing the way physicians practice medicine
byKalisaBarratt,JD,SMSstaffattorneyandMarkL.Adams,JD,CAE,SMScorporatecounsel
57 Third in a series
Practical considerations regarding ethical questions in the daily practice of medicine
byMariaVanCleve,SMSCommissiononMedicineand Ethicsstaff
59 Obituaries
60 County society news
61 Physician briefs
63 Bayfield County to have model program
65 Classified ads
Our cover: Partnerships in familymedicine. This issueexplorespartnerships and trends in family medicine, from
inside residency programs, within our medical schools, between disciplines and, even, among family members.
Theme articles are in the index. Photo of Dr BenGrafatUW Clinics-Research Parkby Bob Rashid (related storv,
p. 37).
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Opinions
President's page
Carpe Diem
"It is a paradox that in our timeofdrastic change,
when thefuture is in our midst devouring thepresent before oureyes,
ive have never been less certain about what is ahead ofus."
—Eric Hoffer
am sitting in my hotel room, in
I AMA
attendanceatthe interim
meeting,asIwritethismonth. While
traveling to DC, on "thebestairline
in the air." I picked up a magazine
and started to read a report on
BusinessWeek's "Health Care Sum-
mit," a futuristic conference for top
business management. I was taken
aback by what I read.
The consensus of the business
leadersinattendancewasaclearrec-
ognitionofthecriticalrolethatphy-
sicians should play in the ongoing
health transformation. They voiced
frustration at having to wait for us
toabandonourcurrentresistanceto
change. Indeed, a note of disap-
pointment in the dearth of leader-
ship by physicians was communi-
MD
cated. Commentswere madeon the Marcia J. S. Richards,
apparent lack of organization of
physicians,an ironicstatementcon-
sideringmycurrentparticipation in business,theycannotallow thecur- the problem themselves.
a meetingoftheAMA,anorganiza- rent situation to persist and they Theleadersofindustryfeelmuch
tion thatisthoughttobestrepresent have assumed the leadership role. like many ofus. They would prefer
the collective voice of medicine. Most see thebill for medical care of working on their primaryvocation,
Hope was expressed that we, as their employees as a cost of doing but will take on others for the sur-
physicians,willseizetheleadership business. We are a necessary sup- vival of their business. Notice the
roleinreformingthehealthcaresys- plier for their industry to continue. parallel, as most ofuswould rather
tem.ManyCEOsindicated thatthey But, like a third partyvendor, ifour care forpatientsthannegotiatecon-
really didn't want to lead the costsare toohigh, or thequality too tracts.Yes,thebusinessleaderswant
changes in health care. But because low, (notice the middle ground be- us to seize the day. And I had be-
ofthefinancialconsequencestotheir ing value) they will step in to solve Continuedon nextpage
WisconsinMedicalJournal•January 1996 5
Continuedfrom precedingpage the Japanese cars arrived on the ation will be temporary.
lieved that businesses wanted the westernshoresoftheUS. Wedonot Butfortunatelyformostinmedi-
lead dog position. They said, if accept, or truly believe, that the fu- cine there is a deep concern about
medicine can run parallel with us, ture will be dramatically different. the future of our profession. Many
ata reasonablepaceand inasimilar Therefore, we have not yet re- of us are still in training and ex-
direction,thenphysiciansandother sponded with the needed vigor to tremely anxious about the current
providersofhealthcareservicescan the tides of change that wash on situation. I appreciated this even
set the rest of the game plan. medicine's shores. Remember the more after talking with the student
Yes, many of us will have addi- ensuing years when the percentage and residentphysician leaderswho
tional constraints under new medi- ofAmerican-made cars on the road attended this AMA meeting. Addi-
cal practice styles, but so do most dropped, and "Made in America" tionally, with the increased output
other professions if they are to sur- was often second best. How times of our training programs (half) of
vive in a world-based society. Little have changed with innovative de- physiciansareunder50yearsofage
room is left for cottage industries, a sign, new manufacturing tech- andhaveatleast15-20yearstoprac-
style of business that many small niques,and attention toqualitycon- tice.
practices have more in common trol. The best value in cars are now ThisNewYear-whetheryouplan
with than with large corporations, made at home. Perhaps this is why many years of medical practice or
who purchase our services. Look wehaveseensuchattentionpaidby are concerned about the future-
around you. Medicine is taking on the foreign auto makers to luxury even if you are graying at the
the corporate model. That is not to cars.Theyareattemptingtobecome temples (or experimenting with
say that cottage industries can not like the physicians of Harley Street other colors as I am)—resolve to ac-
often flourish and grow. They do, in the area ofauto sales. cept the challenge put forth by
but usually if successful, they ulti- For others of us, we see the Americanbusinessleaders. Become
mately integrate or are acquired. changesoccurringinmedicineasan involved, demand or accept leader-
Againnotetheuncannysimilarities. intrusion,andonlyhopethatwecan shiprolesinthereformofhealthcare
Perhapsasphysicians,thesesimi- survive until we cash in our retire- delivery.
larities are parallel to the situation ment chips. Yet others, blindly be- Yes, seize the day. Carpe diem.
oftheauto makers in Detroit, when lieve (orwish) that the current situ-
6 Wisconsin Medical Journal •January 1996
EVP
report: The viewfrom here
Guiding the wanderers
Teacher— One whokindlyguides thewandereron his way.
—Quintus Enniuse
WASDEEPLYSADDENEDlast month (NCMS) as director ofGovernmen-
I
to receive a telephone call in- tal Affairs. I was 29 years old and
forming me of the passing of my fresh from 3 yearsofwork onCapi-
friendWilliamB.A.J.Bauer,MD (See tol Hill in Washington, DC, where 1
obituary by Russell King on page had been "lobbied" many times.
59). As he lay dying of cancer. Dr While I had never done any lob-
Billcalled andasked metovisithim bying myself, the NCMS had for
athishomeinLadysmith. Ifirstmet many years retained John Huske
Dr Bill when he was honored at the Anderson, Esq., as its lobbyist and
StateMedicalSociety's50YearClub advocate with the Legislature.
luncheon in 1989. From that meet- When I met and worked with John
ing we developed a delightful pen he was 74 years old and going
pal friendship thatopened my eyes strong. During our year together,
to so many thoughts and ideas. John was my mentor, teaching me
During my occasional travels in whatIneeded toknowtoeffectively
northern Wisconsin, would take represent the medical profession.
I
time from my schedule to drive to Among other things, he taught me
Ladysmith to spend an enjoyable never to quit, never give up on an
evening, laughing and talking with issue until the last possible vote in
a friend. thelastpossiblevenuehasbeencast. Thomas L. Adams, CAE
Duringmylastvisitwith him,Dr That advice has served me and the
Bill reflected on his life and the organizations where I have worked
mentoring role that so many other well during the past 18 years. gram. The program is run through
physicians had played in his own In my conversation with Dr Bill theSMS'sYoungPhysiciansSection
life. With all the changes medicine he frequently referred to what he (YPS),which includesphysicians40
is experiencing he was hopeful that had learned from others. years and younger.
the role of mentoring, which he He related to me how much his Nearly50YPSphysiciansinvari-
deemed a critical part of medicine, father, who also was a physician, ous specialities are mentors to resi-
would not disappear. It's amazing, influenced his medical career. His dents. Theprogramallowsresidents
hetoldme,howmuchyoucanlearn father often told him, and he later intheirlastyearofresidencytocon-
from shadowing another physician learned himself, that so much of tact a young physician in an area of
fora day. Listeninghow they teach your practice will not be what you thestateorintheirspecialityandask
a diabetic patient healthy diet learned in medicalschool, butwhat them questionsabouttheirpractice.
choicesorwatchinghowacolleague youlearnfromyourcolleagues. (For Thisallowsresidentstogeta feel for
performs a delicate procedure are a look on the influence of a parent what the physician climate is like
justtwoexamplesofhowphysicians inachild'scareerchoiceofmedicine, beforetheymakeanymajordecision
can absorb information from their please see our story this month on on where they would like to prac-
colleagues. You can learn many three family physician parent-child tice. It's an excellent program de-
wonderful things, he said, from teams in Wisconsin). velopedbyourYPSand it's thefirst
watchingandlisteningtootherphy- Through Dr Bill's writings, step for residents of what we hope
sicians, no matter what their age. whether in the form ofa syndicated will includea lifetimeof mentoring
That conversation got me think- monthlyadvicecolumnorhisbook. experiences.
ingaboutthementorsinmylifeand OutofDr. Bill's Black Bag, he strived Forthoseyoungphysiciansinter-
how much we all rely on the pass- to help others and to teach through ested in getting involved in
ing ofknowledge from one genera- his wealth ofexperiences. mentoring a resident, please call
tion to the next. My discussion with Dr Bill re- SMS Field Representative James
Eighteen years ago I joined the mindedmeofoneoftheStateMedi- Reuter, who staffs the program, at
North Carolina Medical Society cal Society's own mentoring pro- Continuedon nextpage
WisconsinMedicalJournal•January1996 7
Continuedfrom precedingpage bers, Jackie Millar, was shot in the records, she was shot in the back of
1-800-362-9080, [phone] orvia back of the head by two teenagers. theheadbytwoteen-agecarthieves.
e-mail [email protected]. Since that column, both of the boys Both face charges, including at-
Dr Bill Bauer was a special man. whoallegedlyshotJackiehavebeen tempted homicide, in adultcourt in
Those of us lucky enough to have waived into adult court. Jackie re- Sauk County. Jackie works as a
been his students will miss him mainsinfairconditionatUniversity meeting planner at Lakeside Asso-
greatly. Hospital where we've been told by ciationServices,Inc.,asubsidiaryof
familymembersthatshe'smadetre- SMS. Shehastwosonswhoarestu-
An update onJackie's condition mendous progress. She's talking, dents at the University of Wiscon-
Mylastcolumndiscussed a tragedy smiling and in physical therapy. sin-Platteville. Wecontinueto pray
that hit a little too close to home Jackie was visiting a friend in for her and her family.*:*
when one our own SMS staffmem- Reedsburgwhen,accordingtocourt
Guest editorial
Understanding where we
are,
where we want and how
to be, to get there
JWohn Frey, MD, Madison
J.
isconsinhasbeen a remark- past 20 years has tried to hit what what motivates young doctors to
ably supportive environ- seems like a moving target, at first train as family physicians in the
ment for family practice, both recommending thetrainingofmore state. A personal tie to the state is
through themandateoftheLegisla- physicians and then years later ap- among the most important reasons
ture which helped bring family pearing to retrench and say thatwe that medical graduates choose to
medicine education to the medical might be training too many - or come here, or stay here after medi-
schools and through the develop- training the wrong types of physi- calschool,asresidents.Thestatehas
ment of large multispecialty group cians. Learning how to notspin out flourished in filling residency posi-
practiceswhich havevalued family on an icy road, I was instructed 30 tionsinpartbecauseithasbeenable
physicians as members. This envi- years ago by my father, was learn- toattractresidentsfromotherstates.
ronmentcannotbeignored. Healthy ing to not jerk the wheel hard but Since historically two thirdsoffam-
plants grow in healthy soil. turn into the spin and accelerate ily practice residency graduatesbe-
However,familymedicineeduca- yourwaybacktothestraightahead. gin practice within one hundred
tion has not been immune to the American medical education has milesofwhere they train,attracting
changing funding and organization appeared not to have learned how students from other states to train
of health care. The search for the to drive on icy roads and as a result here as residents will net a large
rightmixofgeneralistsand special- feels likeweare outofcontrol, orat number of future family doctors.
istscontinuestobea search forboth least threatening to be if we aren't Should the number of graduates of
the proper ratio and theproperdis- clear about where exactly we want theUWand MCWwhochoosefam-
tribution of physicians for the to go. Whereweshould goiswhere ily practice residencies increase, as
peopleofthestate.Aseriesofwhite we always should be heading and those of us involved with student
papersandnationalreportsoverthe that is to keep our eyes clearly on education feel it must, it may de-
the needs of all types of communi- creasesubstantiallytheimmigration
ties and the needs ofour patients. of non-Wisconsin medical school
Dr Frey is chair of the Dept of Family HuestonandSuechting1pointout graduates who train here.
Medicine for theUniversity ofWiscon- thattheplanningfortraininginWis- On theotherhand, ifthenumber
sinMedicalSchool. consinrequiresanunderstandingof of graduates choosing family prac-
Wisconsin MedicalJournal •January 1996