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北京脐带血库变形记 /《科学新闻》2010年第2期
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发表时间:2010-02-03
更新时间:2010-02-03
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北京脐带血库变形记

  记者:田鹏 丁丽丽
  《科学新闻》2010年第2期

  北京妇产医院门诊大厅。凌晨就来排队挂号的准爸爸们,被“男士止步”的
告示牌挡在产科诊室的门外,他们心中忐忑又无事可做。

  在这种情景下,“脐带血库”很容易捕获他们的注意力。

  北京市脐带血造血干细胞库(以下简称北京脐带血库)的咨询柜台就位于产
科诊室的旁边。咨询人员对每一位上前询问者都笑脸相迎,滔滔不绝地讲述脐带
血干细胞的种种独特好处和储存的必要。发放的宣传手册上,醒目地印着:“储
存脐血 ,一生只有一次的机会”。

  脐带血库分为公共库和自体库,公共库存放无偿捐献的脐带血,捐献者不需
要支付保管费用,但是他们除享有配型优先权外,对已捐献的脐带血造血干细胞
再无任何权益。自体库存放自愿付费为新生儿或家人储存的脐带血。在实际的储
存中,公共库和自体库没有明显的差别。

  北京脐带血库自体造血干细胞储存18年的费用为16000元左右。在年轻的父
母们为此付出了这笔不菲的代价之后,究竟能得到怎样的应用和保障?

  当记者表明身份,索要储存协议的复印件时,咨询台的工作人员却找出种种
理由推脱;尽管几分钟前,一对年轻夫妇刚刚拿走了相同文件的复印件。

  咨询台的工作人员避免使用“公司”等词汇,但记者在宣传手册的最后还是
看到了一家外商投资企业子公司的名字——北京佳宸弘生物技术有限公司(以下
简称佳宸弘)。而记者辗转得到的《脐带血造血干细胞储存协议》上,乙方就是
佳宸弘,法定代表人是郑汀。

  佳宸弘公司位于北京亦庄经济技术开发区,其容量高达50万份脐带血的新液
氮库,今年4月刚刚投入使用。

  记者在其脐带血库参观时看到,佳宸弘客服部门和财务部门一派忙碌景象。
他们的主要业务是脐带血自体储存。

  低效的自体库,仅有的1次应用

  拥有6万份的自体库,迄今为止只有1例得到应用;并且,没有证据证明这唯
一一例必须采用自体脐带血。

  实际上,关于脐带血自体库是否必要,本身就存在很大争议。

  2008年7月,新西兰Otago大学儿童癌症研究小组的 Michael J. Sullivan
在《自然》的一篇文章中直指:“在没有已发表的证据支持自体或无特定目的的
家庭脐带血造血干细胞存储的情况下,商业的脐带血自体库是多余的服务。”

  相比较而言,专家们认为脐带血公共库则会发挥更大的作用。北京军事医学
科学院基础医学研究所的唐佩弦研究员在2008年对媒体表示,一个脐带血公共库
达到6000份,配型成功几率就会达到95%左右。他对《科学新闻》说:“脐带血
自存的目的是盈利性的,和公益性的国家公营的脐带血库完全不同。在大陆,由
于国家无力支持公益性的脐带血库,所以全世界的异基因脐带血移植蓬勃发展,
而中国很少医院做异基因脐带血移植。”

  在2009年12月发表在Stem cell reviews and reports的一篇文章中,美国
哈佛医学院的副教授、麻省综合医院白血病研究项目的负责人Karen Ballen指出:
在过去的20年间,全世界约有40万份脐带血储存在公共库中,其中约1.4万份应
用于无亲缘关系异体的临床治疗。而储存在自体库中的约 90万份脐带血,仅有
约100份应用于自体移植。

  根据佳宸弘的资料,截至2009年11月底,北京公共库的总存量只有不到8000
份,记者在佳宸弘档案库中看到的最早的公共库档案记录年份是 1999年。北京
公共库的脐带血共应用了253份。在中国大陆地区,北京脐带血库的应用份数最
多。而该公司自2002年启动、如今已拥有6万份的自体库,迄今为止只有1例得到
应用。

  在佳宸弘的宣传材料中反复提及的1例自体脐带血干细胞移植治疗神经母细
胞瘤的病例,在北京儿童医院血液科4病区完成,主治医师是秦茂权,手术完成
于2009年4月1日。该宣传材料称:“当初妈妈的明智举动挽救了孩子幼小的生
命。”

  在接受《科学新闻》采访时,秦茂权解释,治疗神经母细胞瘤需要大剂量的
化疗,但化疗后病人造血功能无法恢复,需要将外周血或脐带血中的造血干细胞
输回病人体内,恢复其造血功能。真正清除肿瘤细胞的是大剂量的化疗。

  据上述佳宸弘的宣传材料称,“北京儿童医院治疗此类疾病通常采用自体外
周血移植,但经过检查后,病童的外周血中也存在这种致病的肿瘤基因,于是医
生决定使用患者自体存储的脐带血进行移植。”

  针对这种说法,秦茂权说:“对于这个病人来说,她的脐带血我们进行过检
验,确实没有神经母细胞瘤细胞。如果脐带血中没有肿瘤细胞,而外周血中可能
含有肿瘤细胞的话,用脐带血有可能减少复发。”但是秦茂权也明确表示:外周
血“也能用”。因为有文献报道,化疗后的外周血中实际上也检测不到肿瘤细胞。

  “外周血中有没有肿瘤细胞相对于身体中的肿瘤细胞而言没有太大的意义。”
而“外周血中也存在这种致病的肿瘤基因”的宣传语,在医学专业人士看来存在
明显的概念错误。

  正规的公共库还规定如果供者被诊断为白血病,其捐献的脐带血会立即从公
共库中清除和废弃,不得供任何人使用。自体库中的脐带血造血干细胞又怎能用
于白血病儿童的治疗?

  失衡的“公共-自体”比

  儿童患病必须用自体造血干细胞移植治疗的情况发生几率极低。相对地,在
公共库找到配型相合的干细胞的几率却很高

  在一篇2009年10月发表在Obstetrics and Gynecology文章中,加州大学旧
金山分校的Anjali Kaimal等人从成本和效果角度指出:只有数量很少的儿童可
能会用到自体库存储的脐带血造血干细胞进行干细胞移植。因此,父母在考虑为
孩子进行自体脐带血储存时,应该被告知将来用到这些干细胞的机会微乎其微。

  根据美国血液与骨髓移植学会(ASBMT)2008年3月关于自体脐带血采集和保
存的一份报告,自体脐带血应用的概率大致介于 1:2500(0.04%)至1:200000
(0.0005%)之间。且在多数情况下,应首选异体造血干细胞。学会委员会作出
的建议是:1.应尽量鼓励准父母把他们的新生儿脐带血捐献给公共库。2.应告
诉准父母,即使可以付费保存孩子的脐带血,这份脐带血用到自己孩子身上的机
会也是很低的(大致相当于产妇的分娩死亡率),而对于脐带血长期冻存后的细胞
活性和自体脐带血移植的成功率目前还知之甚少。3.应指导已选择自体脐带血
保存的父母,仔细审阅他们的合同和经济责任,了解库存脐带血的质量标准、有
核细胞中位数及脐带血库的认证情况。

  美国妇产科学会(ACOG)和儿科学会(AAP)也都大力推荐父母捐献脐带血。

  在世界范围内,脐带血的自体库存量都大于公共库(大约为9:4)。而在中
国大陆,公共库的发展和自体库的增长相差更为悬殊。北京脐带血库中的公共库
存量只有自体库存量的约1/8。

  作为以营利为目的公司,通常缺乏内在动机致力于公共库的发展,却有极强
的动机令自体库增长。主管行政部门不给予脐带血储存提供资金,具体做法是要
求进行自体脐带血储存业务的公司建立和维持公益性的公共库。

  佳宸弘的首席执行官邓钺在接受《科学新闻》采访时说:“国家不会批准单
纯以营利为目的的脐带血库,即只做自体库的脐带血库。现在的脐带血库有很大
的责任是建立公共库。但国家并不投入资金,所需运营资金全部由脐带血库自己
筹集。相关法规上,除脐带血库设置的硬件要求外,脐带血库还必须具备筹集资
金的能力。”

  关于主管部门对公共库的要求,邓钺表示:“北京脐带血库审批时,国家有
相关规定,公共库必须存够3000份,且运营(时间)必须在3年以上,必须有5例
移植成功病例,达到这些条件,卫生部才会接受申请,才有入门的资质。”至于
公共库和自体库的规模比例,“国家没有规定”。

  北京脐带血库的监管部门是北京市卫生局。该部门一位官员说:“现在(存
量)数量不是很大问题了,主要(问题)在质量上”,她表示储存时间达到一定
长度时,脐带血的质量会下降。公共库在存量达到一定程度后,提高质量更有意
义,应该“不断地更新,让其保持新鲜”。很明显,自体库无法更新。对于公共
库和自体库按一定比例发展的观点,她说:“这意见非常好!”

  另一方面,由于对脐带血干细胞的储存和应用缺乏了解等原因,一般民众又
希望别人向公共库捐献干细胞,而自己储存自体干细胞。一位大学刚毕业进入公
司的年轻女职员直言:“既然脐带血只有一份,确定一定会自存。再说,即使我
存在自体库里的(干细胞)不能用,我还是可以用公库的,别人不可以用我的,
我可以用别人的,如果捐到公库里,万一自己那份被用了,自己在公库里又找不
到合适的配型,那怎么办?”

  入库标准的相对宽松,或许也是自体库迅速膨胀的原因之一。2006年,上海
曾经发生检验不合格的脐带血干细胞被存入自体库中的事件,一时间舆论哗然。
但时至今日,在北京自体库和公共库的入库检验依然采用不一样的标准。

  例如,根据佳宸弘咨询人员的说法,自体库入库标准对于有核细胞数的要求
只有公共库要求的1/5。而现在脐带血造血干细胞应用的最大局限是每份脐带血
中的细胞含量低。北京市卫生局则表示:“标准应该是一样的。”

  标准不一使得自体库的入库前的检验合格率远高于公共库的合格率。这有可
能会导致储存样品中有核细胞数过少,临床应用时细胞量不足。佳宸弘给出的公
共库合格率是约50%,而根据北京市的数据,公共库的实际合格率更低,例如
2009年的合格率只有约17.7%(607/3432),而2008年则只有约 10.6%
(405/3814)。

  难以保障的用户利益

  不可抗力事件在合约中规定不由佳宸弘承担责任:自体造血干细胞应用的几
率极小,按照其赔偿办法,佳宸弘处于绝对优势地位

  对于佳宸弘如何保证公益性的公共库运行和自体库用户的权益等问题,邓钺
对《科学新闻》表示:脐带血库整体和每份脐带血都有财产责任险,从而有外部
保障。她也说:不可抗力事件在合约中规定不由佳宸弘承担责任,“但相信国家
会出台相应措施去解决。脐带血库归卫生局管,如果公司破产了,国家会出面调
停。今后如果有任何变更,卫生行政部门会出面干涉,(脐带)血库不是任何一
个人的,是属于国家的!”

  每份保存在脐带血库中的样品都分别冻存在一只血袋和三只小管中。佳宸弘
采取的检验办法是:需要检测时,检验小管中样品。很明显,小管中样品的状况
与血袋中的样品状况不一定相同。

  如果要对已入库的脐带血做检测,唯一的办法是将整份脐带血从液氮罐中取
出,再抽取其中一部分进行检测。但这可能彻底破坏脐带血中造血干细胞。

  而且,一般只对公共库中的样品进行抽查,而自体库“一般不抽查”。佳宸
弘的质量保证部经理魏晓飞说。

  北京市卫生局对脐带血库的抽查主要集中在管理环节,关于抽查结果,该局
的官员表示:“以往发现过问题,要求定期整改。”

  也就是说,用户没有途径了解自己存在脐带血库中的造血干细胞究竟是怎样
的状态。

  不仅如此,自体造血干细胞实际应用的几率极小,会向自体库要求使用自己
造血干细胞的人数也极少。这极少数人只有在将造血干细胞取出后才能知道其是
否受到了妥善的保存。

  如果保存中出现了问题,佳宸弘也处于有利地位,只需赔给这极少数用户每
份区区数万元(约1.6万元用户收费的2倍),并负担从公共库中找到配型基本相
合的干细胞的费用。这些费用与它从数量庞大的自体库用户处收取的费用相比只
是九牛一毛。

  超高的公司收益

  2003年后,金卫脐带血造血干细胞储存业务的经营溢利每年的平均增长率超
过100%;2008/2009财年,该公司此业务的经营溢利更是超过1亿港元

  虽然运营脐带血库的公司要承担公共库的成本,但它们可以在获得许可证后,
从急剧扩张的自体库业务中赚取高额收益。这就可以从经济上解释公司为何大力
推进自体库业务。

  不过,谈到佳宸弘的收益时,邓钺却说:“大方向肯定赔钱,某些方面是赚
钱的。坦率地讲,佳宸弘目前还没有收回投资。”

  但作为佳宸弘的控股母公司,金卫历年的财务报表却显示了在脐带血造血干
细胞储存业务上完全不同的收益状况。

  佳宸弘成立于2001年,是最早参与建立脐带血库的北京纬晓生物技术公司的
子公司。金卫于2003年收购了佳宸弘,进入了脐带血造血干细胞储存业务。到
2007年5月金卫的该项业务扩展到广东之前,佳宸弘是其唯一从事该项业务的子
公司。

  在收购的第一年,金卫的造血干细胞储存及应用业务的营业额为373.7万港
元;随后4年,北京脐带血库的经营溢利每年的增长都超过100%。到2006/2007财
年,北京库的营业额达到6394.2万港元,经营溢利高达2514.2万港元,较上一年
飙升123%。

  在金卫造血干细胞储存及应用业务的版图成功从北京扩展至广东省的
2007/2008财年,该业务的经营收益上升到6281.1万港元,升幅高达150%。

  而至2009年3月底为止的2008/2009财年,该公司造血干细胞储存业务的经营
溢利更是超过1亿港元。

  2009年,金卫将其造血干细胞储存业务分拆,成立了中国脐带血库企业集团
(China Cord Blood Corporation)并于11月19日在纽约证交所上市,当时的市
值约为4亿美元。

  在金卫令人目眩的资本运作的背后,是造血干细胞自体存储业务的高速扩张。

  被收购的道培医院

  在金卫的高级管理层和顾问委员会列表上,多位媒体在报道脐带血库时所咨
询的首选专家位列其中

  2001年,商业化的脐带血造血干细胞自体库刚刚出现时,受到了众多专家的
反对,其中包括中国工程院院士陆道培等。但到了2009年,自体库不但获得了批
准还急速扩张,陆道培和一些专家在媒体上似乎也转变了态度。

  2008年1月,陆道培在接受中央人民广播电台新闻纵横采访时,还对于移植
“自体”脐带血干细胞的劣势做了如下陈述。

  “从理论上讲,一些遗传性、先天性的疾病是不可能通过自体移植根治的,
从骨髓干细胞移植开始,自体移植的效果就不好。遗传性的病自体移植不可能好,
因为自己的基因本来就有缺陷,你怎么能自己的能治好自己的?一定要别人的干
细胞来移植。”

  但2009年4月,在佳宸弘的《脐带血通讯》中,他又阐述了“自体”移植的
优势:“脐带血中含有丰富的未成熟的造血干细胞,可用于治疗多种血液系统疾
病;而自体储存脐带血一旦需要使用时,无须配型,细胞活脐带血,无免疫排斥
的危险,移植成活率高,治愈率高,医疗费用低。如果病人保存自己的脐带血,
那么我一定会首选病人自己的脐带血来对其进行治疗。因为自体脐带血的基因和
配型完全相合,不会出现移植后的移植物抗宿主反应和排斥现象。”

  《科学新闻》发现,金卫集团在2008年6月宣布已经收购了中国最大的民营
血液病专科医院——道培医院集团的管理权,以形成完整的产业链,“产生巨大
的协同效应”。

  而陆道培恰恰是道培医院的医学总监。此外,陆道培也名列金卫的顾问委员
会之中。

  引人注目的是,陆道培和其他几位血液方面的专家正是媒体在报道脐带血库
时多次咨询的专家。

  对于记者认为陆道培前后观点矛盾的问题,他对《科学新闻》说:“我没有
发表负面观点!我在医学上是独立的,金卫不干涉我。我是从道培医院领工资,
我现在和脐带血库没有任何经济上的联系,没有他们的股份。医院(与他们)的
联系我也说不好,我可以告诉你,原来医院是营利性的,现在是不营利的,所有
持股的人不能分红,这个医院将来是社会所有的。”

  根据佳宸弘的说法,12月30日,在北京道培医院要进行一例脐带血造血干细
胞移植治疗再生障碍性贫血——这将是中国第一例自体造血干细胞治疗再生障碍
性贫血。去年12月31日,《科学新闻》再次致电陆道培,他表示其人在上海,但
30日的造血干细胞移植应该已经完成,但拒绝回答是否持有道培医院的股份。道
培医院方面则拒绝就是否进行了手术做出回答。

  矛盾的法规

  国家并不为公共的脐带血库投入资金,而是默许运营自体库业务的公司获取
收益来运转公共库

  2006年施行的《血站管理办法》中明确写着“国家不批准设置以营利为目的
的脐带血造血干细胞库等特殊血站”,和“脐带血等特殊血液成分必须用于临
床”。

  但是正如邓钺所说,国家并不为非营利的公共脐带血造血干细胞库投入资金,
所需资金全部由脐带血库自己筹集。

  北京脐带血库的监管部门是北京市卫生局。对于《科学新闻》关于北京地区
脐带血造血干细胞库的相关问题,北京市卫生局给出了书面回复:“保存脐带血
干细胞是一项耗资巨大的工程,储存成本相当高。我国目前主要还是依靠公司联
合医疗机构来操作。为了能够正常运营,发展自体库也是有必要的。”但是北京
市医政处的官员同时表示不清楚佳宸弘成本和获利的具体情况。

  这就意味着允许运营自体库业务的公司需要获取收益来运转公共库,但主管
部门又没有就两者发展的规模比例做出明确规定。

  佳宸弘的控股母公司、香港上市的金卫医疗科技有限公司(以下简称金卫)
方面的人员称:“关于自体库和公共库(存量)数字上的问题,相关的一些上级
行政机构,也没有给我们明确的规定。”

  对于公共库的应用,佳宸弘始终没有给出详细的信息,只是表示会提供干细
胞给有资质的医疗单位用于临床,也提供给科研单位用于研究。但对于应用的详
细流程和数量没有提供信息。北京市医政处的一位官员则表示,如有需要,可以
要求脐带血库就公共库中干细胞的应用提供信息,但并不要求每一份应用都上报
备案。

  公共库中的脐带血来自无偿捐献,有需要的患者使用公共库中的造血干细胞
所要付出的费用应该只包括用于血液处理、保存、制备等费用。“这些在相关法
规中是有明确规定的”,这位官员还表示。但令人费解的是处理、保存、制备等
环节都在脐带血库完成,所以费用理应由自体库业务的收益承担。对于使用公共
库中造血干细胞具体的收费金额和最后的分配,她表示“还需要落实一下”。

  佳宸弘方面对监管也表示出不满,邓钺就说:“脐带血库生存艰难,国家规
定必须服从,而运营没有任何保护。北京市卫生局接收此脐带血库时,对其性质
做了很长时间的研究,工商局不受理作为(脐带血库)非营利性组织,认为应该
是行业审批,如果是事业单位,应该有事业单位的指标。”

  北京市卫生局的回复中还说,“北京市卫生局不分公共库、自体库,同样对
北京市脐带血库从宣传、采集、运输、制备、检测、存储全过程以及脐带血的临
床应用、脐带血库的管理等各个方面进行全方位的监管,定期对北京市脐带血库
及脐带血采集医疗机构进行监督检查。”但《科学新闻》在采访中发现佳宸弘在
宣传推广活动中有明显诱导新生儿的父母进行自体储存的行为。

  在接听《科学新闻》电话时,北京市卫生宣传中心的一位官员也谈及:对于
脐带血库“应该严格管理。但卫生部没有具体的管理办法、做法。很多(事)都
不明确,但新生的东西扼杀掉也是不明智的。脐带血造血干细胞还是有价值的,
但收费较贵。(脐带)血库的管理和应用也是不明确的。关于脐带血怎么储存,
怎么应用,还有自体库、公共库怎么协调,以及经济效益、收费的问题都是挺敏
感的问题。”

  北京市卫生局就《科学新闻》“北京市脐带血造血干细胞库运营和监管”等
相关问题的书面回答:

  科学新闻:当前国家卫生部门对脐带血造血干细胞库的运营模式和监管措施
如何?

  北京市卫生局:脐血库分为公共库和自体库。公共库接受公众脐血捐赠,免
费保存,支持公用;自体库收费保存,仅为自用。保存脐血干细胞是一项耗资巨
大的工程,储存成本相当高。中国目前主要还是依靠公司联合医疗机构来操作。
为了能够正常运营,发展自体库也是有必要的。

  卫生部要求,相关的省级卫生部门要按照《献血法》《血站管理办法》和有
关《脐带血造血干细胞库设置管理规范和技术规范》,加强对各地脐带血库的执
业监督管理,规范脐带血库的质量。北京市卫生局在2008年出台有《北京市卫生
局关于加强脐带血造血干细胞临床采集管理的通知》,进一步加强对北京地区脐
带血采集的管理。

  当前,北京市卫生局的监管措施具体有:通过北京市采供血质量控制中心、
临床输血质量控制中心和临床检验质量控制中心,对脐带血采集、冻存和检测质
量不定期抽查和监督;采供血机构年度质量审核;每年两次的卫生监督检查,内
容包括标本抽检和质控检查等。

  科学新闻:对于自体库和公共库监管措施不同,是否会推出新的监管措施?

  北京市卫生局:北京市卫生局不分公共库、自体库,同样对北京市脐带血库
从宣传、采集、运输、制备、检测、存储全过程以及脐带血的临床应用、脐带血
库的管理等各个方面进行全方位的监管,定期对北京市脐带血库及脐带血采集医
疗机构进行监督检查。

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1   [USMcdEdu 于 2011-02-07 20:59:29 提到] [FROM: 199.]
发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

发信人: USMedEdu (US_CMGs), 信区: Biology
标 题: Re: 生活是美丽的。
发信站: BBS 未名空间站 (Thu Jan 27 18:13:03 2011, 美东)

Terra Firma — A Journey from Migrant Farm Labor
to Neurosurgery

Alfredo Quiñones-Hinojosa, M.D.

http://content.nejm.org/cgi/reprint/357/6/529.pdf
“You will spend the rest of
your life working in the
fields,” my cousin told me when
I arrived in the United States in
the mid-1980s. This fate indeed
appeared likely: a 19-
year-old illegal migrant
farm worker, I
had no English language
skills and no
dependable means of
support. I had grown
up in a small Mexican
farming community,
where I began
working at my father’s
gas station at
the age of 5. Our
family was poor, and
we were subject to the diseases
of poverty: my earliest memory
is of my infant sister’s death
from diarrhea when I was 3 years
old. But my parents worked long
hours and had always made
enough money to feed us, until
an economic crisis hit our country
in the 1970s. Then they could
no longer support the family,
and although I trained to be a
teacher, I could not put enough
food on the table either.
Desperate for a livable income,
I packed my few belongings
and, with $65 in my pocket,
crossed the U.S. border illegally.
The first time I hopped the fence
into California, I was caught
and sent back to Mexico, but I
tried again and succeeded. I am
not condoning illegal immigration;
honestly, at the time, the
law was far from the front of my
mind. I was merely responding
to the dream of a better life, the
hope of escaping poverty so that
one day I could return home triumphant.
Reality, however, posed
a stark contrast to the dream. I
spent long days in the fields picking
fruits and vegetables, sleeping
under leaky camper shells,
eating anything I could get, with
hands bloodied from pulling
weeds — the very same hands
that today perform brain surgery.
My days as a farm worker
taught me a great deal about
economics, politics, and society.
I learned that being illegal and
poor in a foreign country could
be more painful than any poverty
I had previously experienced.
I learned that our society sometimes
treats us differently depending
on the places we have
been and the education we have
obtained. When my cousin told
me I would never escape that life
of poverty, I became determined
to prove him wrong. I took night
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
PERSPECTIVE
n engl j med 357;6 www.nejm.org august 9, 200530 7
jobs as a janitor and subsequently
as a welder that allowed me to
attend a community college where
I could learn English.
In 1989, while I was working
for a railroad company as a welder
and high-pressure valve specialist,
I had an accident that
caused me to reevaluate my life
once again. I fell into a tank car
that was used to carry liquefied
petroleum gas. My father was
working at the same company.
Hearing a coworker’s cry for help,
he tried to get into the tank; fortunately,
someone stopped him. It
was my brother-in-law, Ramon,
who climbed in and saved my
life. He was taken out of the
tank unconscious but regained
consciousness quickly. By the time
I was rescued, my heart rate had
slowed almost to zero, but I was
resuscitated in time. When I
awoke, I saw a person dressed all
in white and was flooded with a
sense of security, confidence, and
protection, knowing that a doctor
was taking care of me. Although
it was clear to me that our
poverty and inability to speak English
usually translated into suboptimal
health care for my community,
the moment I saw this
physician at my bedside, I felt I
had reached terra firma, that I had
a guardian.
After community college, I was
accepted at the University of California,
Berkeley, where a combination
of excellent mentorship,
scholarships, and my own passion
for math and science led me to
research in the neurosciences. One
of my mentors there convinced
me, despite my skepticism, that
I could go anywhere I wanted for
medical school. Thanks to such
support and encouragement, I
eventually went to Harvard Medical
School. As I pursued my own
education, I became increasingly
aware of the need and responsibility
we have to educate our country’s
poor.
It is no secret that minority
communities have the highest
dropout rates and the lowest
educational achievement levels
in the country. The pathway to
higher education and professional
training programs is not
“primed” for minority students.
In 1994, when I started medical
school, members of minority
groups made up about 18% of
the U.S. population but accounted
for only 3.7% of the faculty in
U.S. medical schools. I was very
fortunate to find outstanding
minority role models, but though
their quality was high, their numbers
were low.
Given my background, perhaps
it is not surprising that I
did not discover the field of neurosurgery
until I was a medical
student. I vividly remember when,
in my third year of medical
school, I first witnessed neurosurgeons
peeling back the dura
and exposing a real, live, throbbing
human brain. I recall feeling
absolute awe and humility —
and an immediate and deep
recognition of the intimacy between
a patient and a doctor.
That year, one of my professors
strongly encouraged me to
go into primary care, arguing
that it was the best way for me
to serve my Hispanic immigrant
community. Although I had initially
intended to return to Mexico
triumphant, I had since fallen
in love with this country, and
I soon found myself immersed
in and committed to the betterment
of U.S. society. With my
sights set on neurosurgery after
medical school, I followed my
heart and instincts and have tried
to contribute to my community
and the larger society in my own
way. I see a career in academic
medicine as an opportunity not
only to improve our understanding
and treatment of human diseases
but also to provide leadership
within medicine and support
to future scientists, medical students,
and physician scientists
from minority and nonminority
groups alike.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
n engl j med 357;6 www.nejm.org august 9, 2007
PERSPECTIVE
531
My grandmother was the medicine
woman in the small town in
rural Mexico where I grew up.
As I have gotten older, I have
come to recognize the crucial
role she played not only in instilling
in me the value of healing
but also in determining the
fate and future of others. She was
my first role model, and throughout
my life I have depended on
the help of my mentors in pursuing
my dreams. Like many other
illegal immigrants, I arrived in
the United States able only to
contemplate those dreams — I
was not at that point on solid
ground. From the fields of the
San Joaquin Valley in California
to the field of neurosurgery, it
has been quite a journey. Today,
as a neurosurgeon and researcher,
I am taking part in the larger
journey of medicine, both caring
for patients and conducting
clinical and translational research
on brain cancer that I hope will
lead to innovative ways of fighting
devastating disease. And as
a citizen of the United States, I am
also participating in the great
journey of this country. For immigrants
like me, this voyage still
means the pursuit of a better
life — and the opportunity to
give back to society.
An interview with Dr. Quiñones-Hinojosa
can be heard at www.nejm.org.
Dr. Quiñones-Hinojosa is an assistant professor
of neurosurgery and oncology and
director of the brain-tumor stem-cell laboratory
at Johns Hopkins School of Medicine,
Baltimore, and director of the braintumor
program at the Johns Hopkins
Bayview campus.
Copyright © 2007 Massachusetts Medical Society.
Terra Firma — A Journey from Migrant Farm Labor to Neurosurgery
Pay for Performance, Version 2.0?
Thomas H. Lee, M.D.
“Old wine in a new bottle.” “A
financial gamble.” “An early
glimpse of the next generation of
pay for performance.” All these
appraisals have been applied to
Geisinger Health System’s new approach
to elective coronary-artery
bypass grafting (CABG), which
has been described with words
rarely invoked in health care, such
as “promise” and “guarantee.”
Geisinger, an integrated health
care delivery system in northeastern
Pennsylvania, promises
that 40 key processes will be
completed for every patient who
undergoes elective CABG — even
though several of the “benchmarks”
are to be reached before
or after hospitalization. And although
Geisinger cannot guarantee
good clinical outcomes, it
charges a standard flat rate that
covers care for related complications
during the 90 days after
surgery.
As a member of Geisinger’s
board of directors, I have watched
this program evolve over the past
year, and I see truth in all three
of the above assessments. Many
of the core components of the
program are familiar, but this
sort of application of those components
represents a foray into
the unknown. Since a front-page
article in the New York Times on
May 17, 2007, drew national attention
to the Geisinger program,
other hospitals have been
watching closely and wondering
whether they, too, should go
down this road. Those who examine
it closely will quickly discover
that the program is less
about cardiac surgery than about
the search for an alternative to
traditional fee-for-service care.
The basic concept is far from
radical. The seven cardiac surgeons
in the Geisinger delivery
system agreed on 40 processes
that should be completed during
the care of every patient undergoing
elective CABG. Most of
the “Proven Care Benchmarks”
come directly from guidelines
established by the American College
of Cardiology and the American
Heart Association (ACC–AHA)
(see box). These steps (such as
the administration of preoperative
antibiotics at a specified time)
are prominent in the critical pathways
in use for cardiac surgery
at many other hospitals.
The list does not force the surgeons
to practice “cookbook medicine.”
For example, they do not
necessarily have to use epiaortic
echocardiography to screen for
atheromata before manipulating
the aorta. But the protocol requires
that they consider this test
and document the reason if they
decide not to use it.
Closer inspection reveals some
other items on the list that would
be new to most critical pathways
for CABG. The first benchmark
that must be documented is a
statement of the indication for
CABG according to the ACC–AHA
guidelines.1 These guidelines de-
Copyright © 2007 Massachusetts Medical Society. All rights reserved.

Downloaded from www.nejm.org at THE OHIO STATE UNIV on August 26, 2007 .
--
力刀 于加拿大
北美中国医(学)生教育网站:
http://bbs.cmgforum.net or http://cmgforum.net
MITBBS_美国医学教育博客(USMedEdu):
http://www.mitbbs.com/pc/index.php?id=USMedEdu
MITBBS美加临床医学考版俱乐部(Pre_Resident_Club):

 
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