America's Best Hospitals
Tomorrow's cures usually are born at the nation's research hospitals. Here's a look at a few breathtaking breakthroughs
The modern era of audacious medical accomplishments might be said to have begun in 1967, when South African heart surgeon Christiaan Barnard took a beating heart from a 25-year-old woman, brain dead after an auto accident, and fitted it into the chest of Louis Washkansky, 55, alive but barely, with a damaged heart of his own. In the decades since, some breakthroughs have softened into the commonplace. Parents-to-be exult at an image of their developing fetus clear enough to show its sex; with a grin, the doctor hands them a Polaroid of the sonogram to paste into the family album. But miracles continue to unfold. That is especially so in the laboratories and operating rooms of the medical centers that appear in "America's Best Hospitals." As good as most community hospitals are at providing basic health care, major research institutions take the lead in pointing the way to tomorrow's medicine. Barnard's breakthrough of nearly 30 years ago has been perfected to the point that more than 150 American hospitals now perform heart transplants routinely. Washkansky lived for 18 days with his borrowed heart. Nowadays heart-transplant recipients have nearly an 80 percent chance of living at least two years, and many live a decade or more. As expertise grows and spreads, not only more people but more kinds of people benefit. Elderly people with badly damaged hearts have been ineligible for transplants because the scarce organs are thought better allocated to younger patients who presumably have a greater chance of survival. But four years ago, at UCLA Medical Center, doctors fixed up a heart that was below the standards for a normal transplant and used it. They performed quadruple bypass surgery on the donated heart of a 52-year-old woman, then transplanted it into the chest of James Taylor, now 72 and in fine fettle. The UCLA alternative-transplant team remains the only one in the country that takes older, less desirable hearts, mends them and transplants them into elderly patients. All the way at the other end of the age speCenterum, doctors at a handful of institutions around the country are diagnosing--and correcting--life-threatening defects in fetuses weeks or even months before they are born. A benign chest tumor, for example, can crowd the lungs and compress the heart, putting the fetus into heart failure. N. Scott Adzick, director of the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia, says the tumors can be picked up through ultrasound and removed surgically while the fetus is still inside the mother's uterus. Surgical procedures have been done as early as the 18th week of gestation (full term is 40 weeks), sometimes using fetoscopy, inserting a flexible endoscope through tiny incisions in the mother's uterus. Fetal surgery began only in the late 1970s, with researchers experimenting on sheep in hospital-based labs. Able researchers and glittering technology can accomplish nothing without cooperative, courageous patients. At some point, new drugs or treatments that might benefit children move from animal studies to adult human beings. But sooner or later, it is time to bring children into the picture, and that is when parents and young patients need a highly supportive institution. "Everything is geared toward making the child comfortable, from emergency rooms to waiting rooms, from security people all the way to the leadership of the institution," says Kwaku Ohene-Frempong, director of the comprehensive sickle cell center at Children's Hospital of Philadelphia. His pilot study testing the drug hydroxyurea on 12 young sickle cell patients was successful enough to win a grant from the National Institutes of Health to develop a multicenter study of 75 children. Pondering the possible. With an institutional culture encouraging research and generating patient trust, scientific minds are free to rove, ponder--and create novel uses for technology. A hot new tool of the 1990s called a confocal microscope is being used at Massachusetts General Hospital in Boston to look deep into layers of living tissue and analyze cells that previously could be viewed under a microscope only after biopsy. The device, now in preliminary clinical studies, spots skin-cancer cells by peering through layers of living tissue with a laser beam. Someday, in a kind of scalpel-free biopsy, the microscope might quickly diagnose other cancers, such as cervical or esophageal. "In a place like Mass General, you get a lot of eager young minds asking the kinds of questions that stir you up," says Robert Webb, a physicist who along with dermatologist Rox Anderson and research fellow Milind Rajadhyaksha developed the living-tissue cell-detection method. Peering without cutting obviously is easier on patients. So is the trend, when cutting is necessary, toward smaller incisions. This method, sometimes called keyhole surgery, now encompasses even heart procedures such as bypass surgery and leaves a scar as small as an inch. Lawrence Cohn, chief of cardiac surgery at Brigham and Women's Hospital in Boston, who this month performed a keyhole aortic-valve replacement that left a somewhat larger scar of about 3 inches, summarizes minimalist heart surgery from the patient's perspective: "You don't crack the sternum, you minimize blood loss and you reduce recovery time, pain and the length of the hospital stay," he says. All of that, of course, pays off for the hospital in lower costs. That is hardly trivial in the current health care marketplace, where institutions prowl for savings that will keep them solvent. The patient's perspective is different: Such breakthroughs save lives and reduce suffering. And induce grateful astonishment.
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