Bradford J. Shingleton, M.D.
The Ophthalmic Consultants of Boston
50 Staniford Street
Boston, Mass. 02114
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Dear Dr. Shingleton,
.PP
.na
Thank you letter of January 19.
I have mailed
to Mr. Tormachy in the admitting office
the scheduling request form which you provided
and I look forward to working
together with you in the Emergency Department.
The purpose of this letter is to ask your help
in resolving, before I begin my work,
certain administrative problems which I describe below.
.PP
The Infirmary, if I understand it correctly,
intends to designate me as attending physician
and operating surgeon for certain seriously ill patients 
who are likely to come to the Emergency Department while I am on duty.
Judging from my past experience in similar situations, I believe that
the Infirmary expects me to delegate the performance of 
any required surgical operation
in part or in whole to residents for training purposes.
I am under the impression that the Infirmary expects me also to
sign operative notes and or discharge summaries that make it appear
as if I had in fact fulfilled
the functions of the patient's attending physician
and as if I had in fact personally performed the operations in question.
If my restatement of the Infirmary's requirements is erroneous,
please accept my apologies and provide me
with written confirmation to the contrary.
.PP
I do not wish to disparage those of my colleagues
who are able to reconcile the apparent contradiction
in the Infirmary's demands,
and to declare under penalties of perjury
that they have served as operating surgeon in a case where all,
or almost all operative manipulation has been done by someone else.
However, to reach such a conclusion
presupposes dialectic skills which transcend my intellectual capacity.
I recoil from presuming to pass judgment on others,
but I have no alternative to passing judgment on myself.
My conscience tells me that in my case,
the representations that I believe are required of me would be fraudulent
and would place me in jeopardy having my license revoked by
the Board of Registration in Medicine
and in the case of patients who are beneficiaries of
Medicare or Medicaid in jeopardy also
of criminal and civil monetary
penalties under the federal false claims act.
.PP
The problem seems to me to be readily soluble.
The suggestion which I respectfully submit to you
for your approval is as follows:
After I have examined a patient requiring surgery
I will discuss the recommended treatment with the resident.
I will then give the resident the opportunity
to explain to the patient in my presence,
the nature of the disease and of the 
surgical treatment that he or she proposes to administer,
thereby establishing him or herself in the patient's
mind as a competent and caring physician.
The resident may be instructed, if the Infirmary wishes,
at that juncture to offer the patient
my services as attending physician and operating surgeon
as an alternative to his or her own.
I would prefer avoid that responsibility, 
but if I were asked, I could not and would not refuse.
Depending then on the patient's choice,
the operation would be the resident's case or my own.
Either I would assist the resident-surgeon at the operation,
or the resident as assistant would help me.
The operative note, which I would co-sign in either case,
would clearly indicate who had performed which steps of the procedure.
In cases where I actually perform the surgery myself,
I am pleased to permit the Infirmary to collect
fees in my name. I expect no remuneration.
But if the resident performs the operation,
I would ask that the Infirmary refrain from making
claims that might lead a government agency to assume that
I had rendered services which were in fact performed by the resident.
.PP
Finally,
to those patients whose surgery I have done myself,
I consider it essential
that I also render postoperative care.
The reason is not to increment my practice,
which is already larger than I wish,
but becasuse I believe a surgical operation inflicts not only
physical but also emotional injury on the patient,
and the healing of the emotional wounds requires
continuing attendance by the responsible physician.
That presence certainly prevents much potential litigation.
Since I do not have, and do not expect to be offered,
suitable office space in the Infirmary,
I intend to invite my postoperative patients to visit me
in my Cambridge office until such time as they
have recovered from surgery.
.PP
Please do not consider these proposals
in any sense an ultimatum.
There are other strategies for resolving our dilemma,
but I believe what I have outlined
to be the most constructive.
I should not be at all upset if you reject my suggestions.
In that case they might serve as a starting point
from which we search for a compromise.
The only thing which I consider essential is that,
when I start my Emergency Department career,
I have in hand a set of clear and unambiguous 
written instructions from you
compliance with which will satisfy the claims
of the Infirmary to my professional services.
Permit me to stipulate that if
I receive no reply from you, I shall infer your consent
to the terms of this letter.