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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EDITOR'S NOTE After Pages 68 to 87 went to press, an error was discovered. The Mayo Clinic should be listed as a member of the Council of Teaching Hospitals (COTH) in all applicable specialties. Its score for cancer care should be 47.6; cardiology, 96.0; endocrinology, 95.1; geriatrics, 60.1; otolaryngology, 42.9; and urology, 83.8. The corrected scores do not affect Mayo's rankings in these specialties.
THE HONOR ROLL To make the U.S. News honor roll that defines America's elite hospitals, a hospital had to rank among the top 10 in at least three specialties and score at least 10 points. Points were based on 10 for a No. 1 ranking, 9 for a No. 2 ranking and so on, down to 1 point for a No. 10 ranking. 1. Johns Hopkins Hospital, Baltimore (117 POINTS IN 15 SPECIALTIES) 2. Mayo Clinic, Rochester, Minn. (109 POINTS IN 15 SPECIALTIES) 3. Massachusetts General Hospital, Boston (89 POINTS IN 11 SPECIALTIES) 4. UCLA Medical Center, Los Angeles (52 POINTS IN 10 SPECIALTIES) 5. Duke University Medical Center, Durham, N.C. (47 POINTS IN 10 SPECIALTIES) 6. Cleveland Clinic (37 POINTS IN SEVEN SPECIALTIES) 7. University of California, San Francisco Medical Center (31 POINTS IN SEVEN SPECIALTIES) 8. Brigham and Women's Hospital, Boston (25 POINTS IN SIX SPECIALTIES) 9. University of Texas M.D. Anderson Cancer Center, Houston (22 POINTS IN FOUR SPECIALTIES) 10. (TIE) Barnes-Jewish Hospital, St. Louis (18 POINTS IN FOUR SPECIALTIES) 10. Memorial Sloan-Kettering Cancer Center, New York (18 POINTS IN FOUR SPECIALTIES) 12. University of Washington Medical Center, Seattle (16 POINTS IN FOUR SPECIALTIES) 13. University of Iowa Hospitals and Clinics, Iowa City (16 POINTS IN THREE SPECIALTIES) 14. New York University Medical Center (12 POINTS IN THREE SPECIALTIES) 15. University of Michigan Medical Center, Ann Arbor (11 POINTS IN THREE SPECIALTIES) 16. Stanford University Hospital, Stanford, Calif. (10 POINTS IN FOUR SPECIALTIES)
[Photograph captions]: Prebirth assist. Still 14 weeks from his due date, this fetus undergoes surgery at the University of California, San Francisco Medical Center to repair a hole in his diaphragm. A temporary plug has been inserted in his trachea. It will keep normally expelled lung fluid in the lungs, helping to accelerate lung growth after he is returned to the uterus.
Mission: Conception. Penetrating the membrane of a human egg in a petri dish, a thread-thin glass needle injects a single sperm--invisible within the tip even in this enlarged photograph--directly into the ovum's fluid center. The egg was removed at the University of California, San Francisco Medical Center from a woman whose mate suffers from azoospermia, a condition in which no sperm are present in the ejaculate, usually because of a vasectomy or infection. Instead of millions of sperm racing to be first to penetrate the egg, this technique, called intracytoplasmic sperm injection, provides one lucky sperm with a direct hit and results in a fertilized egg about 70 percent of the time. The egg is then transferred to the uterus. UCSF has done more than 100 single-sperm injection fertilizations; its 35 percent success rate equals that of the center's ordinary in vitro fertilization program. "You need a team," says UCSF reproductive endocrinologist Carolyn Givens: "a urologist with special training in obtaining the sperm. Someone skilled in andrology [male infertility]. A good IVF team. And people skilled at micromanipulation."
Spotting danger. The bright white on the lung in the image at left, from a total body PET (positron emission tomography) scan, is a "hot spot" where cancer cells are multiplying. The cells have picked up the radioactive tracer injected into a patient at Duke University Medical Center. Not all hot spots alarm. Spots in the pelvic area show where the tracer is being excreted, a spot on the left arm where it was injected. But a tiny white spot on the right arm and another one in the upper rib area are more bad news. The tracer is drawn to cancer's unusually active cells, and the image shows that the cancer has spread to the bones.
Heartbreak. Cleveland Clinic surgeons have just removed a slice of living heart that its owner is better off without. Pioneered by Brazilian surgeon Randas Viela Batista, ventricular remodeling--removal of part of the wall of a dangerously enlarged heart--is showing positive results at a handful of U.S. centers. Patrick McCarthy of the Cleveland Clinic's department of thoracic and cardiovascular surgery was among the physicians who went to Brazil to watch the technique and examine Batista's patients--whose survival rate was comparable with those for heart-transplant patients. In patients with congestive heart failure, the surgery can relieve stress and let the heart pump more efficiently. Conceived as a bridge to transplant, the technique works so dramatically in some patients that transplant is no longer necessary.
Staving off pain. Sabriyah King, 8, mixed up her first dose of hydroxyurea when she was only 3. The breakthrough medication can ease the pain that racks many sufferers of sickle cell anemia. Since Sabriyah began taking the drug (which she says tastes like chalk) through Children's Hospital of Philadelphia, she has not had any painful episodes. She is in a study to see whether the drug might reduce complications such as gradual destruction of lung tissue.
This story appears in the August 12, 1996 print edition of U.S. News & World Report.