A few days after the Knoxville Surgical Society voted to censure him in 1987 for criticizing the region's trauma care system, Dr. Kimball I. Maull stepped out of his office at the University of Tennessee hospital to give a pep talk to his staff.
"They've censured me, they've sued me and the only thing left is to castrate me," said Dr. Maull, already a nationally known trauma surgeon, in his deadpan drawl. "But they'll have to catch me first."
After coming to Baltimore just five months ago to take the $233,000 job as head of the Maryland Institute for Emergency Medical Services Systems, Dr. Maull already is engaged in another struggle with his fellow doctors.
The surgeon fired three physi cians at the Maryland Shock Trauma Center last week, accusing them of trying to undercut his authority. The dismissed doctors parried with a lawsuit and obtained a Baltimore Circuit Court order temporarily blocking their ouster pending a hearing.
Dr. Maull said Friday that he had hoped to avoid a fight. But that didn't stop him from issuing a warning to other would-be mutineers.
"I do not contemplate any further terminations," he said. "But there are a number of other staff physicians who have yet to declare themselves to be supportive and be part of the new order of things."
Dr. Maull's self-assured declarations seem reminiscent of the style of the hard-charging Dr. R Adams Cowley, the founder and guiding spirit of the Shock Trauma Center, which is the hub of the state's emergency medical network.
That shouldn't be surprising. Dr. Cowley, who died last fall, tried to recruit Dr. Maull for his staff in 1987, saying he wanted the Tennessee surgeon eventually to take over Shock Trauma. (Dr. Maull said he turned the job down because of the political turmoil at Shock Trauma.)
Dr. Cowley made his pitch around the time Dr. Maull was battling Knoxville's medical establishment.
"Dr. Cowley used to say often, 'You can tell the pioneers by the arrows in their backs,' " said Peggy Trimble, former director of nursing and specialty care at Shock Trauma. "That's probably what Dr. Cowley saw in Dr. Maull."
The current struggle between Dr. Maull and the Shock Trauma physicians seems in some ways a resumption of the battles Dr. Cowley fought.
The three doctors fired last week -- surgeons Ameen Ramzy and C. Michael Dunham and critical care specialist Howard Belzberg -- were among 16 who signed a May 1989 letter to University of Maryland officials complaining that Dr. Cowley was making "inexplicable shifts" in policy and creating "general chaos." Dr. Cowley resigned later that month.
But Dr. Maull, a graduate of the University of Virginia and Cornell Medical School, said he didn't come in looking to settle old
"I felt that with new thinking, some fresh thinking, some of the obvious solutions would be possible," he said.
The surgeon, who first became interested in trauma medicine as an Army physician moonlighting in Washington emergency rooms, said he wants to bring the state's emergency medical system up to date.
"I think there's absolutely no question that since Dr. Cowley was forced out, the institute has been lagging behind," he said. "But that's why I'm here."
On the surface, the current struggle at Shock Trauma is over programs and policies. Scratch the surface, both sides say, and it's about money and power.
On July 1, Dr. Maull ordered that Shock Trauma begin admitting people with knife and gunshot wounds from Southwest Baltimore, as envisioned by the state when it agreed to spend $35 million to build the new center.
But since Shock Trauma's new building opened in 1989, the center has continued to focus on treating automobile accident victims, many of them brought in by helicopter.
The new admissions policy met resistance. But Dr. Maull insisted. "It makes little difference if someone is shot with a gun or is run over by a car, we're the state trauma program," he said. "Patients ought to be coming here."
Financially, the move may make a big difference, according to other health care specialists. "The people that drive on the interstates and get into accidents by necessity have insurance and coverage," said one health policy expert familiar with Shock Trauma. "The people who get stabbed on the streets do not."
Nancy Hoyt, a former Shock Trauma staffer and ally of Dr. Cowley, wrote in a 1990 report on Shock Trauma's woes that the center's physicians typically recover only 9 cents on the dollar in fees charged indigent patients, mostly from Medicaid payments.
By contrast, they recover about 94 cents on the dollar from insured patients. (Physicians at the center earn up to about $200,000 annually from fees billed by their for-profit corporation, Shock Trauma Associates P.A., a state official confirmed.)
There is deep disagreement between the center administration and the physicians over what the new policy means. Supporters of the fired doctors say that the new policy may admit many patients whose knife and gunshot wounds are superficial, overloading Shock Trauma's facilities and forcing critically hurt patients to go elsewhere.
And they accuse Dr. Maull and top officials at the University of Maryland Medical Systems of being motivated by the bottom line. UMMS controls both Shock Trauma and University of Maryland Medical Center.
UMMS must treat gunshot and knife wound patients in any case. If it treats them at Shock Trauma, rather than at the emergency room of the UM Medical Center, UMMS can charge 18 percent more for room and board.
Dr. Maull doesn't deny that the added patients will help the Shock Trauma Center financially. But he said that the new policy is a "win-win situation," because it also will ease the patient load at the UM Medical Center's emergency room and make more efficient use of Shock Trauma's staff at times when it is on standby.
Dr. Maull insisted he was not trying to ascribe motives to the fired doctors. But at one point he said: "You know when people say it's not the money, it's the principle? Well, it's usually the money."
Six years ago in Knoxville, Dr. Maull again confronted the status quo when it conflicted with his own plans.
He tried to get the state to designate his University of Tennessee hospital as the city's single, front-line trauma center, where a surgeon would always be standing by, for all serious accidents. Other hospitals resisted, apparently fearful of losing patients, status and fees.
The surgical society voted to censure Dr. Maull several months after he told a reporter in August 1986 that, because the hospitals were trying to block the new trauma system, "nothing will change, and the injured patients will continue to die needlessly."
When pressed, Dr. Maull offered an example fresh in his mind: the case of a 17-year-old boy in a car that slammed into a tree late one Saturday night.
Dr. Maull and his team were alerted and standing by at the University Medical Center. But the helicopter ambulance, owned a group of private hospitals, flew the victim to one of those hospitals instead. But there was no surgeon on duty, and it took the emergency room physician 1 1/2 hours to summon an operating room team. The teen-ager died in surgery.
When the story hit the newspapers, there was a public outcry. Knoxville's doctors were outraged, too. They thought Dr. Maull's comments about the incident were misleading and inflammatory.
Dr. Kent Farris, who was president of the Knoxville Academy of Medicine at the time, said Dr. Maull was urged to tone down his criticism at a series of meetings.
"He never backed down one iota," he said. "He sort of looked down on the [medical] leadership. He certainly didn't respect it."
He called Dr. Maull "a very strong-willed, heavy-ego person, who kind of does his own thing and doesn't perhaps listen to his peers' advice."
While Dr. Maull was instrumental in improving trauma care in eastern Tennessee, Dr. Farris conceded, "I think it was at the expense of some other innocent people and institutions."
Dr. Maull recalled those days as painful ones for him and his family. But he does not regret what he said.