I note with considerable distress the article published under your directorship in the JAMA for December 10, 1973.
Although I am currently on the staff in the National Heart and Lung Institute, I am not expressing official opinions of that
Institute or any other opinions than those which I myself have gained as a result of twenty years as chairman of the Department
of Surgery at the Downstate Medical Center. During that period of years, I served not only as president of the Society for
Vascular Surgery, but also as president of the Society of Surgical Chairman. I believe that the understanding of surgical
problems which I gained in that experience should be of value to you.
I became convinced in the course of building up a program on open-heart surgery at the State University of New York, Kings
County Medical Center, that the evaluation of the quality of highly specialized services on the basis of the frequency with
which those services are rendered is an unsound practice. As an example, there were whole series of patients who had been
denied operation at major medical centers in the New York area on the basis of the complexity of the lesions involved and
the expectancy of high risk, who were admitted at the State University-Kings County Medical Center, meticulously studied and
To judge those institutions which had declined to care for such patients as being of highest quality on the basis of the numbers
of patients for whom they rendered open-heart surgical care seems ridiculous. On the other hand, to threaten to withdraw the
approval of the superbly performing open-heart team at Downstate on the basis of the numbers of cases handled appears equally
out of order.
I may call attention to the fact that the first successful open-heart operation in the Eastern one-third of the United States
with the single exception of Gibbon's initial case was performed at Kings County Hospital. I may also call attention to
the fact that the first clinical application of pump-oxygenator to support for clinical open-heart surgery was performed by
the nucleus of that group at the State University of New York (prior to removal of that group from the University of Minnesota
to State University of New York.
As a measure of the quality of this particular group, this is the first group on record to work with experimental placement
of artificial cardiac valves (five years before Albert Starr), this was the first group to identify electrically the bundle
of His during clinical open-heart operations, this was the first group to apply mechanical cardio-pulmonary support in the
management of massive myocardial infarction and shock (the first patient is still alive after seventeen years) and this was
the first group to work seriously with external compression counterpulsation (the patent for which, obtained by NIH, is in
The State University of New York, Downstate Medical Center, is but one university institution with a record of vigorous contribution
and excellent clinical results which would be removed from further participation by the very rules which the Joint Commission
on Accreditation of Hospitals is proposing to endorse. While it may be appropriate in the general sense of a service-rendering
institution to equate numbers of patients with quality of performance, this is by no means universally the case.
To enforce such a limitation as the requirement of at least 200 open-heart operations per year for approval by J.C.A.H. would
be to exclude from further participation a very considerable group of the major contributors to our knowledge and capabilities
concerning the rendering of the very conditions under consideration.
Judgment must be tied to the quality of the operations done, the complexity of the lesions in question, and the success in
returning those patients to good health.