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We studied all physicians who purchased obstetric malpractice insurance from the Washington State Physicians Insurance Exchange and Association between January 1, 1982 and July 1, 1988. Of the 690 physicians studied, 171 (32% of the family physicians and 10% of the obstetricians) discontinued obstetrics but remained in practice. Physicians who discontinued obstetric practice were older, more likely to practice in an urban area, and more likely to be in solo practice than those who did not. Obstetricians who discontinued obstetric practice had a higher rate of new obstetric malpractice claims than did those who did not quit practicing obstetrics--14.5 versus 6.2 claims per 100 physician-years of coverage. By contrast, those family physicians leaving obstetrics had a lower rate of new claims than their peers who did not quit. We conclude that older physicians--particularly those in urban and solo practice--are most likely to stop practicing obstetrics, regardless of specialty. In addition, being named as the target of an obstetric malpractice claim plays a significant role in the decision of some obstetricians to discontinue obstetric practice.

A survey of techniques used in coronary artery bypass graft (CABG) surgery by 400 experienced cardiac surgeons is presented. These surgeons performed 41,000 CABG operations in 1975. A seventy-question survey form was answered by each surgeon on their techniques for cardiopulmonary bypass and myocardial preservation, choice of bypass conduit, and grafting techniques. We found that extracorporeal circulation is almost always used in CABG surgery. A wide divergence of practice exists in the use of left ventricular vents and in methods of myocardial protection during coronary artery grafting. A spectrum of graft suture techniques is employed, the most common being a running double-ended suture anastomosis with the end of the vein initially fixed only at its heel to the coronary artery. Only 23 surgeons (6 per cent) prefer the internal mammary artery (IMA) rather than saphenous vein, when feasible, as the bypass conduit of choice for CABG surgery.

Surgical therapy for coronary artery disease results in improved survival rates for selected groups of patients, particularly those with left ventricular dysfunction and/or severe coronary artery disease as evidenced by involvement of two or more vessels. Successful augmentation of coronary blood flow as shown by patient saphenous vein graft is associated with improved exercise tolerance when compared with patients in whom the grafts are occluded. Patients with impaired left centricular function as a result of their coronary artery disease appear to experience an improvement in this function with the augmentation of coronary blood flow by patent saphenous vein bypass grafts. In patients with occluded grafts and impaired left ventricular function, the left ventricular function is unchanged. Ptients with normal left ventricular function who sustain occlusion of their grafts will probably experience a reduction in their systolic ejection fraction.