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of course, were initially disappointed in Noseworthy's response,
but ultimately everyone stepped up and did what was asked.
Cardiac surgery was ripe for overhaul. An initial analysis showed
as much as a twofold variation in surgeons' average costs per
case-from $55,000 to $110,000 in one procedure. The operating room teams competed to reduce the time from "wheels
out," when one operation was over, to when the room was set
up for the next operation. Results for each surgeon's room were
posted, and staﬀ met to discuss what worked and what did not.
The exercise trimmed average turnover times about 50% to
between 20 and 30 minutes.
The overhaul eﬀorts revealed two main cost drivers: a patient's
length of stay and the surgeon's use of mechanical heart valves. So
many valve brands were on the shelf it was like going to a shoe
store, the chief of heart surgery indicated. The Mayo Clinic, one
of the US's largest users of such valves, decided to use its purchasing power to negotiate lower prices and limit surgeons to models
from two vendors. It took nearly 2 years for surgeons to agree on
which ones. Everyone eventually came around. Physicians also
began discharging out-of-town patients to a hotel a day or two
before their ﬂight home, and then seeing them for an outpatient
visit. Previously many patients remained in the hospital until just
before their ﬂight. Surgeons accustomed to operating every other
day began operating every day. New physician-developed protocols empowered nurses to streamline postoperative care, making
it more eﬃcient. Some shifts started later in the day to adjust to
staggered operating room start times, to reduce overtime, and to
avoid peaks and valleys in intensive care unit staﬃng. The results
of these changes for cardiac surgery at the clinic reduced costs by
millions of dollars and signiﬁcantly narrowed the variation among
surgeons in costs for heart procedures.
The heart surgery initiative and scores of projects like it
are part of the organization's continuing evolution. Outside
analysts have provided the clinic with projections that over the
next 5 years, its reimbursement could decline from 5% to 20%.
Other top hospitals are also facing cost pressures, including
the Cleveland Clinic, which despite reducing $800 million of
costs over the last 4 years, reported a 71% drop in operating
income in 2016 to $139 million, citing reimbursement pressure, higher drug costs, and pension plan adjustments. Partners
HealthCare, a Boston-based system founded by Harvard-aﬃliated Brigham and Women's Hospital and Massachusetts General,
said it planned to cut $600 million in costs over the next 3 years
to better compete "in a challenging new regulatory, legislative,
and consumer-driven environment."
NEUROSURGERY AND PATIENT H. M.
On September 1, 1953, William Scoville, a neurosurgeon at
the Hartford Hospital in Connecticut, operated on a 27-yearold man named Henry Molaison, who suﬀered from severe
epilepsy (5). Scoville removed the left and right sides of the
hippocampus from Molaison's brain. The hippocampus, located
near the center of the brain, forms a part of the limbic system
that directs many bodily functions, and Scoville thought that
epileptic seizures could be controlled by excising much of that
portion of the brain. The result, however, was a total loss of
October 2017

both short-term and long-term memory. H. M., as he came to
be known in medical writings (his real name was not disclosed
until his death in 2008), could no longer remember anything
he did. He could neither remember what he had eaten for the
day (breakfast, lunch, or supper), nor could he ﬁnd his way
around the hospital. He failed to recognize hospital staﬀ and
physicians whom he had met only minutes earlier, remembering only Scoville, whom he had known since childhood. Every
time he met a certain scientist from the Massachusetts Institute
of Technology who was studying him regularly, she had to reintroduce herself again. He could not even recognize himself
in recent photographs, thinking that the image in the pictures
was some "old guy." Yet he was able to carry on a conversation
for as long as his attention was not diverted. H. M.'s condition
suggested that the hippocampus was essential for the conversion
of short-term memories to long-term memories.
Luke Dittrich, Scoville's grandson, wrote Patient H. M.: A
Story of Memory, Madness and Family Secrets. Much of the book
describes with justiﬁed quiet indignation the failures of the
neurosurgical procedures that were widely practiced by Scoville
and other neurosurgeons in the past century. Much of what we
know about memory today comes from studying H. M. and
the irreparable harm done to him.
BABE RUTH AND NASOPHARYNGEAL CANCER
Gabe Mirkin, who writes frequently on health, ﬁtness, and
nutrition, published a piece entitled "What killed Babe Ruth at
age 53?" (6). Babe Ruth surely was our greatest baseball player.
When he ﬁnished his baseball career, he held the record for
most home runs (714), had a lifetime batting average of 0.342,
batted in 2213 runs, had a slugging percentage of 690, got on
base 47.4% of the time he batted, scored 2174 runs, hit for
5793 total bases, and was walked 2062 times. At age 19 (1914),
Ruth signed to play professional baseball for the minor-league
Baltimore Orioles and was soon pitching for the major-league
Boston Red Sox. He quickly became the best pitcher in baseball,
winning 24 games in 1917. In 1919, he was sold to the New
York Yankees and was converted to a full-time right ﬁelder
because he was also the best hitter in baseball. His teams won
10 pennants and 7 World Series, 3 with Boston and 4 with New
York. He retired at age 40 in 1935 and was one of the ﬁrst ﬁve
players to be elected to the National Baseball Hall of Fame.
In September 1946, Babe Ruth's voice became raspy. He
had headaches and constant severe pain in his left eye. The
physicians told him that he had "sinusitis" caused by infected
teeth, so three teeth were pulled. He then felt worse. His face
swelled, his left eye swelled shut, and he was unable to swallow
food. Radiographs showed a mass in the back of his neck, but
all biopsies were negative for cancer. As the lymph nodes in his
neck enlarged, he couldn't eat, so he had to be fed through his
veins. In November 1946, an operation on his neck allowed
the diagnosis of cancer.
His hoarseness and many years of smoking cigars and drinking lots of alcohol led his physicians, and the rest of the world,
to think that Babe Ruth had cancer of his larynx. He actually
had nasopharyngeal carcinoma that starts in the back of the nose

Facts and ideas from anywhere

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017