To learn why death rates from heart bypass operations varied as
much as 400 percent in a New England study, researchers are
reviving an old practice: Surgeons are visiting each other's
hospitals to watch colleagues operate.
But in a new twist, they are taking engineers,
anesthesiologists, technicians and nurses with them.
The teams are seeking clues to death rates that defied
explanation in a study of 3,055 bypass operations by the 18 heart
surgeons in the five hospitals that do all the bypass operations
performed in Maine, New Hampshire and Vermont.
The effort is a return to the days when surgeons routinely
learned new techniques at first hand from their colleagues. But it
is not the only one.
In the belief that doctors often learn more from mistakes than
successes, surgeons in Europe long ago formed what is known as
Pete's Club, in which members report their biggest surgical
disaster of the past year.
In the United States, 25 heart surgeons belong to a 12-year-old
club that makes informal visits to a member's hospital once a year.
They watch the host perform operations and talk with nurses and
technicians to pick up tips that they often incorporate into their
practices back home, said Dr. Dan J. Ullyot, a heart surgeon at the
University of California at San Francisco and club member.
But unlike the members of Pete's Club and the 25 surgeons, the
researchers in New England intend to publish results of their
efforts to unravel the heart surgery mystery.
The puzzling new findings, along with those of another study
from Philadelphia published in the current issue of the Journal of
the American Medical Association, challenge the prevailing view
that differences in death rates can be explained by simple factors,
like differences in patients' conditions.
They suggest that more complex factors are involved. So the New
England team will consider such factors as drug treatments before
and after surgery, the organization of the hospital and the
personality of the surgeon.
All teaching hospitals once had amphitheaters or domes where
surgeons watched masters perform operations. It was under what
became known as the ether dome at Massachusetts General Hospital,
for example, that surgical anesthesia was first publicly
demonstrated in 1846.
But no such amphitheater was included in the new hospital that
Duke University built 10 years ago because "no one uses them
anymore," said Dr. David Sabiston, the chief surgeon at the Durham,
N.C., medical center.
Instead, many surgeons now learn by watching films or
videotapes of key portions of operations at meetings or on closed
But such "films are often dressed up, so what you see looks
almost perfect, and there's never anything on a film that shows
bleeding and other problems," Sabiston said in an interview.
He added: "Films do not tell you about pre-operative and
post-operative care, and more important, you do not hear the
conversation in the operating room."
Some famous heart surgeons have suffered tarnished images after
visitors have seen them err.
One surgeon told about a colleague who was astonished to watch
a world-renowned surgeon sew a heart valve in upside down. Junior
assistants did not point out the mistake.
As was his custom, the surgeon went on to work on another
patient in another operating room, leaving his assistants to finish
the first operation. Once the master had left, the assistants
repositioned the valve. …