The dark side of report cards

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?"

"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.

A breath.

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 Another flick, and the balloon was withdrawn.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 10 minutes.

This was Sharma's third patient of the day, and he was scheduled for 14 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.

Who's going to take on the tough cases?

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.