Cardiology in Crisis

“When Doctors Slam the Door” by Sandeep Jauhar, M.D., in The New York Times Magazine (Mar. 16, 2003), 229 W. 43rd St., New York, N.Y. 10036.

It must have seemed an obviously good thing to do more than a decade ago when the federal Health Care Financing Admin­istration and several states began monitoring the performance of heart surgeons and other medical professionals. In the early 1990s, New York and Pennsylvania began publishing “report cards” for public consumption. The idea behind all these efforts, notes Jauhar, a New York City cardiology fellow, was “to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons,” channeling patients toward the good ones and forcing the deficient others to heal themselves. The worst surgeons might lose their hospital operating privileges.

At first, there seemed to be amazing improvements. In New York State, for example, “mortality rates for coronary bypass surgery declined a whopping 41 percent.” (Nationwide, surgeons perform some 500,000 bypasses annually.) But skeptics feared that surgeons intent on boosting their scores might be declining to treat their sickest patients. “In a survey a few years ago,” Jauhar reports, “63 percent of cardiac surgeons in New York State said that because of report cards, they were accepting only relatively healthy patients for coronary bypass surgery.” Now there’s hard evidence, too. Researchers at Northwestern and Stanford Universities who compared 1990–93 data from New York and Pennsylvania with data from states with no such report cards found something striking: Patient health-care expenditures over the year before coronary bypass surgery dropped by seven percent in the two states while staying about the same elsewhere. That’s evidence that healthier patients were being “cherry picked” for surgery. The decline in expenditures in New York and Pennsylvania “was matched by a drop in the number of operations for sicker patients. They experienced ‘dramatically worsened health outcomes’ as a result, including more congestive heart failure and recurrent heart attacks,” notes Juahar.

He sees “a kind of spiritual crisis in the field of cardiac surgery. Heart surgeons, among the most highly trained and fearless of specialists, are shrinking from taking on the toughest cases because of statistics.”

The pity of it is that they’re the wrong statistics. Some 98,000 Americans die every year because of medical errors, but seldom is an individual surgeon—or nurse, or technician, or anesthesiologist—solely responsible. “Health care is too complex; outcomes depend on many variables,” Juahar believes. To ensure real accountability, we must focus not on individuals but on the systems that deliver our health care.