People called him crazy. During his four years as the only surgeon transplanting kidneys and hearts at the University of Maryland Hospital, Dr. Thomas Coughlin took exactly two weeks of vacation. The rest of the time, he operated seven days a week and remained on call 24 hours a day -- running a one-man transplant program that, in his words, "was run on a shoestring."
Last June, he left quietly to join the heart transplant team at the Washington Hospital Center in the District of Columbia, home to one of the most prestigious cardiac surgery centers on the East Coast. There, three surgeons perform heart transplants. Six others transplant kidneys.
"I didn't mind doing it for a while, but after a while it gets a little old," Dr. Coughlin said of the program he left in Baltimore. "Some of this was self-imposed. It was a guilt kind of thing." He said he knew that if he left town, there would be nobody left to operate if a heart or kidney suddenly became available for one of his needy patients.
In an era when many patients wait a year or more for donor hearts and kidneys, the idea of passing up an available organ was hard to accept.
His work went far beyond transplants. When hired in 1987, he was asked to do general chest surgery as well -- so he replaced heart valves, performed bypass operations and repaired problems in the esophagus and lungs.
But workload isn't what drove this self-confessed workaholic from Baltimore, he said. Rather, he said it was the Washington Hospital Center's enticing offer and a growing desire to leave the publish-or-perish world of academic medicine, where success depends as much -- and sometimes, more -- on scholarly articles as it does on skill in the operating room.
His departure left the transplant program at University Hospital in a state of limbo. The hospital has no one qualified to transplant kidneys, so while it is busy recruiting new talent, it refers patients to the Washington Hospital Center for surgery when matching kidneys become available.
Soon after Dr. Coughlin left, the hospital hired Dr. John Laschinger of the University of Toronto to perform heart transplants in addition to bypass and valve replacements -- the most common open-heart procedures.
But he has yet to perform a transplant since he arrived. The hospital has only one patient on its waiting list, and that person is waiting for a suitable organ.
Dr. Coughlin said he harbors mostly good feelings about the Baltimore hospital that gave him an opportunity to build a solid reputation as a transplant surgeon. But as the hospital prepares to rebuild its program, he offered this advice:
"I think they need to make up their mind. They need to make a commitment to excellence and to do whatever it takes to do that," he said. "They need to see where their strengths are, emphasize those strengths and fix the weaknesses."
Dr. Stephen Schimpff, executive vice president of the University of Maryland Medical System, said the hospital is firmly committed to rebuilding its heart and kidney transplant programs -- specialties that teaching hospitals increasingly regard as vital to prestige and national standing.
Besides adding Dr. Laschinger, he said, the hospital is planning to hire three surgeons trained to transplant kidneys, pancreases and livers. Dr. Schimpff said the hospital is close to hiring someone to supervise kidney transplants -- and, barring problems, the program could be in business within three or four months.
Dr. Schimpff said he isn't worried about generating business for the kidney program, which has built a solid reputation over the two decades it has been running. Donor organs, although not as plentiful as they were a few years ago, came along with sufficient regularity for the hospital to perform 23 kidney transplants last year.
Heart transplants could be a more difficult proposition. The hospital performed only two heart transplants since it declared itself ready to do them two years ago. Across town, five surgeons at Johns Hopkins Hospital performed 18 heart transplants last year and 11 the year before.
University Hospital simply wasn't getting many patient referrals. In two years, only four patients were referred to the program by doctors and placed on the waiting list for organs. Dr. Coughlin said physicians in the area were reluctant to refer patients to a program that had not yet established a track record, but that wasn't the only problem.
"I also needed more support from our own medical staff in making referrals," he said. "Once it was up and running, I felt we could be doing 10, 12, maybe 15 transplants a year." Dr. Coughlin said he also needed -- but couldn't find -- a staff cardiologist interested in managing transplant patients once they had surgery and got out of the hospital.
"We ran that program without one," he said, explaining that he did the job himself. "The operation itself is not the challenge. The main problem is the management of the patient after they receive the organ."
Transplant programs are not big moneymakers, but they are increasingly regarded as essential for major medical centers wishing to establish themselves as full-service institutions capable of attracting patients and top-flight staff.
Ann Weiland, administrator of Washington Hospital Center's transplant program, said such programs are inherently inefficient because of the uncertainty surrounding the availability of organs. This means procedures cannot be scheduled. Transplant teams must suddenly mobilize themselves -- often in themiddle of the night -- when an organ does come along.
Dr. Schimpff admitted that the hospital will have to do a sales job on area physicians to attract patients needing heart transplants.
"It's like the old ad," he said. "We may be No. 2, but we try harder."