Practice Makes Perfect

If I miss a day of practice, I can tell

a difference in my technique. If I miss

two days, my wife can also note it. If

I miss a week, even the public can tell.

--Ignace Jan Paderewski

The effects of practice and lack of practice are equally apparent among surgeons who operate inside the human heart, say Dr. Ben Eiseman and Dr. Frank C. Spencer of the University of Kentucky. In routine operations standardized by tradition, they say in Circulation (published by the American Heart Association), there is a "ritual of technique" so familiar that "even the occasional surgeon can dabble as an amateur with some safety for his patient." Not so in open-heart surgery.

A study done under the guidance of Johns Hopkins' famed Pediatrician Helen B. Taussig, report the Kentucky doctors, showed that no fewer than 327 (out of 7,000) U.S. hospitals claimed in 1961 to have all the facilities--including a heart-lung machine--for doing open-heart surgery. In that year, 37 of the hospitals reported that their equipment had never been used: not a single open-heart operation. In 97 hospitals where there had been operations, the total was fewer than ten; in 117 there had been from ten to 50. In only 56 medical centers were open-heart surgeons operating often enough to fulfill Paderewski's call for an absolute minimum of weekly practice. The results can be read in the death rate. One of the greatest U.S. surgeons, who operates at least once a week and on many of the world's toughest cases, has a death rate below 5%. Twelve surgeons who were technically qualified but lacked practice had a 30% death rate with less difficult cases, and one of this group lost every patient.

Far simpler than open-heart surgery is closure of a patent ductus arteriosus, the shunt that connects the aorta with the pulmonary artery in unborn infants. Normally, the duct closes automatically soon after birth. When it does not, the situation can be remedied either by tying the vessel shut or by cutting it and closing the ends. In major medical centers, mortality from these operations is near zero. But 777 hospitals offer to do them, and 232 hospitals have admitted a death rate of 3.6% from the first type of operation and 9.6% from the second.

Not only does delicate and dangerous surgery inside and around the heart, especially in infants, demand exquisite skill in the chief surgeon: he must have equally skilled helpers, and they all need as much practice as he does. "Open-heart surgery," say Dr. Eiseman and Dr. Spencer, "unfortunately has a totally undeserved role as a professional status symbol." It is no field, they add, "for those who follow the fads." In recognition of the problem, cardiologists in smaller cities are beginning to refer more of their patients to the busy surgeons in the big centers.

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