Watching the Tissue

In Chicago's Grant Hospital one morning last week, half a dozen physicians gathered for the regular meeting of their medical audit committee. The meeting, like those over the past five years, was devoted to a businesslike examination of the hospital's medical records of the week. In perhaps the most important part of the session, the doctors considered the "tissue reports" of the pathology department. Their main concerns: 1) to see whether parts of the body removed by surgery were really diseased, 2) to see to what extent preoperative diagnosis had been confirmed by surgery.

By one name or another, medical audit committees and tissue committees are becoming common in U.S. hospitals. The American College of Surgeons has been recommending them for a dozen years, and in 1952 the Joint Commission on Accreditation of Hospitals* ruled that no hospital may be fully accredited that does not maintain some such systematic review of surgery. Now, the commission reported this week, 3,418 of the 7,500 hospitals of the U.S. and Canada have systems that qualify.

One of the men most responsible for the new trend is salty, 7 2-year-old Dr. Malcolm T. MacEachern of Chicago, longtime head of the hospital-standardization program of the American College of Surgeons. "When I came on the job in the '20s," says Dr. MacEachern, "tissue specimens were thrown into a pail. Nobody bothered to save them."

Once a systematic study of surgery specimens began, MacEachern and others set out to determine, if they could, the dividing line between necessary and unnecessary surgery. In the year's work of any surgeon, they decided, the removal of a certain amount of healthy tissue is "justifiable." This is partly because of honest mistakes in diagnosis (an appendix may turn out not to be inflamed, after all), partly because some patients are sold on surgery and demand it as a cure-all (many middle-aged women with vague symptoms beg for hysterectomies).

How much removal of healthy tissue is "justifiable" is still an open question. But in many hospitals nowadays, a surgeon whose rate of healthy tissue removals exceeds 15% will be asked to explain himself to the tissue committee and, if need be, to the hospital's executive committee. The ultimate penalty of suspension is rarely necessary.

The possible effect of this kind of scrutiny was reported in an A.M.A. conference last fall. When a tissue committee was first set up in St. Mary's Hospital, Passaic, N.J. five years ago, one appendectomy in every five was found to be unjustified. Current rate: only one in 20.

* Membership: American College of Surgeons, American Medical Association, American Hospital Association, American College of Physicians, Canadian Medical Association

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