On a Tuesday morning not long ago, Samin Sharma strolled into his operating room on the fifth floor of Mount Sinai Medical Center in Manhattan and stood over his patient. The doctor’s assistants had already inserted a thin plastic catheter into a blood vessel in the man’s leg, threaded it into his badly clogged left coronary artery, slid a metal wire tipped with a tiny balloonlike device through the catheter, and scrubbed the offending artery clean. Now, squinting at a television monitor showing a real-time X-ray of the patient’s struggling heart, Sharma began manipulating a second wire to insert a stent, a tiny metal device resembling the springy coil of a ballpoint pen, to keep the offending artery open.
It was at about that time that the patient, a 60-year-old television executive, spoke up. He had been anesthetized locally, affording him the unique privilege of watching Sharma save his life.
“When can I go back to work, Doctor?”
Sharma fiddled with the second wire. “You can go back Monday.”
“How about Sunday?”
“You can go back Sunday also.”
Sharma is a 48-year-old cardiologist who specializes in angioplasty, the increasingly popular minimally invasive procedure he was in the middle of performing. If he finished the job correctly—if the stent he chose fit properly and he installed it without a rupture—blood would again rush through the artery unfettered, helping the man’s heart pump at something like normal capacity. The slightest misstep, however, could burst the vessel, causing a heart attack and, perhaps, even death.
Sharma spoke again. “Okay, my friend. I want you to take a deep breath now.” He needed the patient to keep perfectly still.
With the flick of a finger, Sharma delicately placed the stent. Another flick, and the balloon was withdrawn. On the monitor, the clogged artery opened and the stent held; blood flushed easily past where the blockage used to be.
“Breathe normally now. Very good.”
Sharma gave a nod, left the man to be stitched up by the others, and headed back to his office for a Frappucino. He’d been at the table all of ten minutes.
This was Sharma’s third patient of the day, and he was scheduled for fourteen more. Each week he does about 40; each year, at least 1,100. No one in the state even comes close to doing as many; the runner-up, in Buffalo, does something like 800. Not only is Sharma one of the most popular doctors for angioplasty in New York; as a matter of statistical fact, he has the state’s single-lowest mortality rate. And in New York, where everyone is watching, that now matters quite a lot.
In 1989, New York became the first state in the nation to make public the mortality rates of its heart surgeons. Report cards for two different procedures, coronary bypass and angioplasty, were chosen as the standards by which the entire profession would be judged—a sort of litmus test for the skill of a given surgeon or hospital. The mortality numbers, risk-adjusted by age and other factors, are released every year or so on the Internet and reprinted in newspapers for all to see, hospital by hospital and doctor by doctor. Ending years of private, clubby surgeon culture, the public report cards were intended to shine a light on poor surgeons and encourage a kind of best-practices ethic across the state. If the system worked, mortality rates would fall everywhere from Oswego to NYU.
At first glance, the system seems to have made an enormous difference. Although there’s no satisfying way to compare our risk-adjusted death rates with those of other states (most of which only have data from Medicare patients, who tend to be sicker and therefore skew the sample), the most recent data suggest that in the past fifteen years, New York’s coronary-bypass surgeons have improved their mortality rates to the point that they are, on average, just one-third of what they were. Sharma’s risk-adjusted mortality rate in the latest angioplasty report is an astonishing 0.1 percent, the state’s lowest. In eleven years, he has been the only doctor to have consistently earned the state’s coveted double asterisk, which designates a surgeon with numbers far below the norm. These days, plenty of his colleagues have low numbers, too; everyone has drifted downward together. Like the children of Lake Wobegon, the surgeons of New York are all, apparently, above average.
But the statisticians who devised the report cards have been tormented by a persistent, intractable glitch in the system: It involves human beings. From the start, it was clear that surgeons’ careers were on the line as well as patients’ lives, and even before the first set of data was released, leaders in the heart-surgery community warned with an air of eerie certainty that the threat of public exposure would create a chilling effect—influencing surgeons to turn their backs on the sickest patients in order to prop up their personal success records.