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PERSPE C T I V E Geographic Variation in the Quality of Prescribing

ing (r = 0.30 for the proportion low-quality prescribing were even events that may require addition-
taking high-risk drugs; r = 0.25 stronger and more highly signifi- al expense to treat.
for the proportion taking drugs cant than they were with risk Disclosure forms provided by the au-
thors are available with the full text of this
with potentially harmful interac- adjustment and thus are not an article at
tions with their underlying dis- artifact of risk-coding practices.
eases [P<0.001 for both correla- In sum, according to HEDIS From the Department of Health Policy and
Management, Graduate School of Public
tions]) (see the Supplementary measures of potentially danger- Health, University of Pittsburgh, Pittsburgh
Appendix). In other words, the ous prescribing patterns, the qual- (Y.Z.); the Department of Health Policy and
regions in which nondrug medi- ity of prescribing for the elderly Management, Harvard School of Public
Health (K.B., J.P.N.), and the Department of
cal spending per beneficiary was varies substantially among local Health Care Policy, Harvard Medical School
higher were also the regions in markets — substantially more, (J.P.N.) — both in Boston; and the Harvard
which beneficiaries were more in fact, than does spending on Kennedy School of Government, Cam-
bridge, MA (J.P.N.).
likely to be given prescriptions drugs overall. Our results do not
for potentially harmful or high- support the theory that high- This article (10.1056/NEJMp1010220) was
risk drugs — a finding that does spending areas simply use more published on November 3, 2010, at NEJM
not support the premise that of everything, including inappro-
higher medical spending leads to priate drugs, since the association 1. Zhang Y, Baicker K, Newhouse JP. Geo-
higher-quality prescription use. between overall drug spending graphic variation in Medicare drug spend-
Our measures were adjusted for and inappropriate prescribing is ing. N Engl J Med 2010;363:405-9.
2. The state of health care quality. Washing-
patients’ risk scores, but because weak. In addition, because spend- ton, DC: National Committee for Quality As-
similar patients appear to be cod- ing on nondrug medical care is surance, 2009. (
ed as sicker in high-spending positively associated with a greater 0/Newsroom/SOHC/SOHC_2009.pdf.)
3. The Healthcare Effectiveness Data and
areas than in lower-spending use of potentially harmful drugs, Information Set (HEDIS). Washington, DC:
areas,4 we also examined the our results also do not suggest National Committee for Quality Assurance,
correlation between the quality that more medical spending is 2010. (
measures and medical or drug associated with better health care 4. Song Y, Skinner J, Bynum J, Sutherland J,
spending without adjusting for overall. Our results are consis- Wennberg JE, Fisher ES. Regional variations
patients’ risk scores. Analyzed in tent, however, with an association in diagnostic practices. N Engl J Med 2010;
363:45-53. [Erratum, N Engl J Med 2010;363:
this way, the correlations between between lower-quality prescription 198.]
spending and the prevalence of patterns and more adverse drug Copyright © 2010 Massachusetts Medical Society.

Up in the Air — Suspending Ethical Medical Practice

D. Malcolm Shaner, M.D.

First I will define what I conceive icist. About midflight, a woman left arm. There was none. Two
medicine to be. In general terms, it in the row behind us reached flight attendants approached. “I
is to do away with the sufferings frantically for the baggage bin am a physician,” I said. “Let’s get
of the sick, to lessen the violence of over our heads. I offered to help. him down to the floor.”
their diseases, and to refuse to She was trying to get her hus- We lifted him into the aisle. I
treat those who are overmastered band’s oxygen tank. shined a pocket flashlight on the
by their disease, realizing that in I turned and saw that he dimly lit scene. He had stopped
such cases medicine is powerless. looked to be about 70 years old. breathing; his pulse was absent.
— The Hippocratic Corpus His eyes were closed, and his right We tore open his shirt to reveal
hand was clutching his chest as a well-healed thoracotomy scar.

O ur plane was flying from the

East Coast to the West carry-
ing 167 passengers, including my
he grimaced in pain. Immediate-
ly, his grimace faded and his
right arm dropped. Leaning over
A flight attendant brought an
automated external defibrillator
(AED), an Ambu bag, and other
Comment on wife, a hospitalist and my seat, I caught his hand and equipment. Three other passen-
this article at internist, and me, a neu- felt for a pulse while my wife gers — an oncologist, an anes- rologist and clinical eth- checked for the radial pulse in his thesiologist, and a surgeon —

1988 n engl j med 363;21  november 18, 2010

The New England Journal of Medicine

Downloaded from by Alba Riesgo on November 21, 2010. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE Suspending Ethical Medical Practice

joined us. My wife ran the code, reversible disease when patients found online. As it turned out,
I provided chest compressions, are overcome by illness. This prin- he had also been a physician.
the anesthesiologist bagged the ciple holds true even when fam- We had knowingly delivered
patient, the oncologist managed ily members request futile inter- medically ineffective CPR. But we
the equipment, and the surgeon ventions or when physicians are did so because of practical con-
attempted venous cannulation and following a well-meaning proto- cerns arising from the demands
then intracardiac injection of epi- col. To prolong CPR under the cir- of the airline’s protocol. CPR was
nephrine. We confirmed that there cumstances in which we found going to go forward whatever we
was a femoral pulse only with ourselves would be to subvert decided, and we chose to contin-
chest compressions. medicine’s goal from the good ue it ourselves so that the four
We followed the protocol sug- of the patient to the benefit of flight attendants could attend to
gested by the AED. The device the community. Given this under- their duties during an emergency
did not discharge, since its auto- standing, we could not consider landing.
matic rhythm-detection program our actions to be within the On solid ground, I believe that
had found no rhythm that might scope of the practice of medi- medical policy and protocols
be treated with defibrillation. The cine; rather, as we continued ad- should preclude such dilemmas.
monitor eventually showed a wide ministering CPR, we were acting The responsibility for deciding to
complex bradycardia with which less as physicians than as skilled stop CPR should rest with a phy-
we could not associate a palpa- passengers assisting a flight crew. sician who is focused solely on
ble pulse. The pilot announced that he the good of the patient. CPR
Our resuscitative efforts were was diverting the plane to a small should be deemed ineffective
taking place in full view of the airport. The crew calmed the when it cannot be expected to
passengers and the man’s wife, passengers, addressed their oth- meaningfully alter the natural
who stood beside us. Five previ- er needs, and attended to land- course of the disease; it should
ously rambunctious children were ing preparations. As we descended be deemed futile when it no lon-
now silent. steeply, the pilot ordered every- ger serves the patient. We should
After 25 minutes of basic car- one to be seated. The anesthesi- ensure that our medical policies
diac life support, there was still ologist and oncologist complied. and protocols exclude consider-
only pulseless electrical activity. We were down to two physicians ations such as mitigation of lia-
The five physicians agreed that administering CPR. A flight at- bility or the exclusive interests of
it was time to stop the code and tendant took over the use of the third parties from playing a role
declare the patient dead. But the Ambu bag and required coaching in resuscitative decisions. Such
flight attendant explained that if on technique. I was instructed to policies will help support the ef-
we stopped CPR, the airline’s pro- hold onto my wife as she contin- forts of physicians to act always
tocol would require the cabin crew ued chest compressions, both of for the good of the patient and
to continue it in our stead. “This us half-strapped into stretched within the bounds enunciated in
is futile,” muttered the surgeon, safety belts to allow us to con- the Hippocratic Corpus.
and without discussion, he re- tinue CPR during the landing. The views expressed in this article are
turned to his seat, leaving four of We landed with a light bump, those of the author and do not necessarily
reflect those of the institutions with which
us facing a dilemma: If we turned then braked and taxied along the he is affiliated.
the resuscitative efforts over to the 6500-ft runway to a stop. The Disclosure forms provided by the author
crew, who would look after the resuscitative efforts had contin- are available with the full text of this arti-
cle at
passengers? But if we continued ued for some 35 to 40 minutes.
CPR, we would be treating a pa- Firefighters and paramedics ar- From the Department of Neurology, Kaiser
tient who had clearly been “over- rived and carried the patient to Permanente Medical Care Program, West
Los Angeles Medical Center; and the Depart-
mastered” by his disease. the door and down a fire-truck ment of Neurology, David Geffen School of
The proper practice of medi- ladder. He died that day, accord- Medicine, UCLA — both in Los Angeles.
cine does not include treating ir- ing to news reports we later Copyright © 2010 Massachusetts Medical Society.

n engl j med 363;21  november 18, 2010 1989

The New England Journal of Medicine
Downloaded from by Alba Riesgo on November 21, 2010. For personal use only. No other uses without permission.
Copyright © 2010 Massachusetts Medical Society. All rights reserved.