Correspondence
Cardiopulmonary Resuscitation on Television
N Engl J Med 1996; 335:1605-1607November 21, 1996
- Article
To the Editor:
We reviewed 113 articles published over a three-decade period to calculate the rate of survival to hospital discharge after cardiopulmonary resuscitation (CPR).1 Long-term survival after in-hospital CPR was 15.2 percent (95 percent confidence interval, 14.8 to 15.6 percent) on a worldwide basis, with 3968 of 26,095 patients surviving to hospital discharge. For U.S. patients, long-term survival was 14.7 percent (95 percent confidence interval, 14.1 to 15.3 percent), with 2026 of 13,766 patients surviving (78 studies). In our analysis, survival varied according to the location of CPR. Survival was better after CPR in the emergency department (23.3 percent; 95 percent confidence interval, 21.3 to 25.3 percent) than after CPR in the intensive care unit (14.7 percent) or medical ward (12.5 percent).
In applying a binomial test, Diem et al. (June 13 issue)2 used 30 percent as the reference rate because this was the highest long-term survival rate (found in a single report) in their review of the literature. The authors found that the survival rate after CPR on television programs (67 percent) was significantly different from 30 percent (P<0.001). Our U.S. long-term survival rate (14.7 percent), a more accurate reference rate calculated from 78 studies, was only half the rate used by the authors. Comparing 15 percent with 67 percent enhances the authors' points about the misperceptions of patients regarding the outcomes of CPR and the obligation of physicians to advise and counsel their patients.
On the other hand, survival after CPR in selected patients (healthy, young adults with unexpected cardiac arrest due to trauma or surgery) may be as high as 70 percent (not unlike the survival rate in the television shows), as was reported in the first study of modern CPR by Kouwenhoven et al.3 The problem in the television shows, then, is not so much inaccurate survival statistics as it is faulty representation of patients. The vast number of patients who undergo CPR every day in hospitals are not children and young adults, but chronically ill, elderly persons with limited life expectancies. But who wants to see reality on television shows?
3 ReferencesRonald J. Markert, Ph.D.
Wright State University School of Medicine, Dayton, OH 45401-0927Mohammad G. Saklayen, M.D.
Veterans Affairs Medical Center, Dayton, OH 454281
Saklayen M ,Liss H ,Markert R . In-hospital cardiopulmonary resuscitation: survival in one hospital and literature review. Medicine (Baltimore) 1995;74:163-175
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Diem SJ ,Lantos JD ,Tulsky JA . Cardiopulmonary resuscitation on television -- miracles and misinformation. N Engl J Med 1996;334:1578-1582
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Kouwenhoven WB ,Jude JR ,Knickerbocker GG . Closed-chest cardiac massage. JAMA 1960;173:1064-1067
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To the Editor:
Having viewed 97 episodes of ER, Chicago Hope, and Rescue 911, Diem et al. take issue with the producers for portraying an excessively optimistic picture of CPR. Perhaps the following messages relating to medical interventions are also unduly optimistic: “Mammography helps your doctor see breast cancer before there is a lump, when the cure rates are near 100 percent.” 1 “Given the overwhelming evidence that [colorectal-cancer] screening is effective in detecting and curing this second deadliest cancer. . . . ”2 “Most women with breast cancer could be saved by detection . . . with mammography.” 3
The surprising feature of these and many other upbeat messages is that they originate from medical practitioners and health care agencies rather than from fictional television characters. We agree with Diem et al. that producers of hospital dramas should recognize a civic responsibility to be more accurate. However, such idealism should also apply to the medical profession itself.
3 ReferencesHugh E. Mulcahy, M.D.
Martha M. Ellison, M.B.
Michael J.G. Farthing, M.D.
Royal London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom1
American Cancer Society. Pamphlet 86-(30mm). No. 2077-LE. Washington, D.C.: American Cancer Society, 1986.
2
Colorectal cancer bill introduced: AGA coordinates coalitionAGA News 1995;29:12-12
3
Strax P . Control of breast cancer through mass screening: from research to action. Cancer 1989;63:1881-1887
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To the Editor:
Diem et al. may not be the only physicians watching the television program ER. Since ER first aired on September 22, 1994, the number of fourth-year students at Indiana University School of Medicine enrolling in emergency medicine residency programs has doubled (Table 1Table 1
Number of Fourth-Year Students Enrolling in Emergency Medicine Residency Programs.). Although other factors, such as market forces, may also be involved in this significant increase (2 SD from the mean of 3.2 percent), the omnipresence of television may now be influencing physicians' career choices.1 ReferencesEliot M. Wallack, M.D.
Glenn J. Bingle, M.D., Ph.D.
Community Hospitals Indianapolis, Indianapolis, IN 46219To the Editor:
The analysis by Diem et al. demonstrates a higher-than-expected survival rate for patients undergoing CPR in television portrayals. However, neither these authors nor Baer in the accompanying editorial (June 13 issue)1 addresses the quality of the CPR performed. What might be the effects of a viewer's attempting CPR after learning the technique from watching television? It is known that the ability of a layperson to provide adequate compression and airway control depends on the quality2 and frequency3 of training and that even after formal education, CPR skills are often inadequate.4 Certainly, the implicit risks of adopting “bad” CPR skills suggest that learning how to perform CPR from a television drama may do as much harm as obtaining a false impression of its success.
4 ReferencesMilan Chheda, B.A.
Harvard Medical School, Boston, MA 02115Paul J. Hauptman, M.D.
Brigham and Women's Hospital, Boston, MA 021151
Baer NA . Cardiopulmonary resuscitation on television -- exaggerations and accusations. N Engl J Med 1996;334:1604-1605
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Korttila K ,Vertio H ,Savolainen K . Importance of using proper techniques to teach cardiopulmonary resuscitation to laymen. Acta Anaesthesiol Scand 1979;23:235-241
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Weaver SJ ,Ramirez AG ,Dorfman SB ,Raizner AE . Trainees' retention of cardiopulmonary resuscitation: how quickly they forget. JAMA 1979;241:901-903
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Berden HJ ,Bierens JJ ,Willems FF ,Hendrick JM ,Pijls NH ,Knape JT . Resuscitation skills of lay public after recent training. Ann Emerg Med 1994;23:1003-1008
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To the Editor:
Since 1988 I have offered CPR courses to various community groups, and I usually ask each class, “What motivated you to come today?” Invariably, at least half the students refer to one or more of the popular medical dramas discussed by Diem et al. and Baer, and often a lively exchange follows as students recount events of a particularly spectacular CPR-based “save” in some episode. It is refreshing to see television motivate people to learn a valuable skill, and I applaud the producers for this wonderful outcome.
On the other hand, although Baer rightly asserts that physicians often communicate poorly with patients regarding end-of-life issues,1,2 this does not excuse producers of medical dramas for the inaccurate portrayals of the outcomes of CPR, in terms of survival or subsequent quality of life. On the contrary, their burden should be proportionally greater, given that these programs reach and clearly influence millions of viewers.
2 ReferencesAnnette Troy, M.S.
Medical College of Pennsylvania–Hahnemann University School of Medicine, Philadelphia, PA 191291
Frankl D ,Oye RK ,Bellamy PE . Attitudes of hospitalized patients toward life support: a survey of 200 medical inpatients. Am J Med 1989;86:645-648
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The SUPPORT Principal Investigators
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To the Editor:
Medical shows are rarely accurate, but neither are legal shows, detective shows, police shows, and sometimes, even game shows. The results of CPR on these shows are just a small example of the inaccuracies. When does a physician take more than a two-line history? In what emergency room does a physician deliver eight babies a day, perform gastroscopy, or open a belly to cross-clamp an aorta with a leaking aneurysm? What hospitals function like the ones on television? A professional playwright and screenwriter, who was also a lawyer, once told me, “In the end, we do what works for the dramatic — even if the truth has to be ignored.”
Stephen A. Borowsky, M.D.
18546 Roscoe Blvd., Northridge, CA 91324To the Editor:
As one of the technical advisors to the television show Chicago Hope, I must confess that the idea that CPR was being presented as too successful never crossed my mind. Accuracy in the presentation of CPR was what was thought to be important in the event that someone might actually learn the technique from watching the program.
Since the accuracy of the success rate of CPR has been identified as the problem to be addressed, it might be appropriate for the subject of the next study of this kind to be the number of shots that a cowboy can really get from a six-gun as opposed to the number we see him get.
What fascinated me most about this article was that three physicians studying television shows to evaluate the impression that CPR might have on the viewer did not realize that every hour of the 97 hours they watched included 16 minutes of commercials designed specifically to bend their minds, mold their opinions, and influence their decision to buy, buy, buy some product.
D. Gareth Wootton, M.D.
Pacific Surgicenter, Santa Monica, CA 90404To the Editor:
. . . Dr. Baer ignores the powerful influence television has on the public's agenda of vital health care issues.1 He states, “We have no evidence . . . that watching these programs directly affects viewers' personal choices about CPR.” Similarly, there is no evidence that proves the contrary. . . .
1 ReferencesJohn M. Byrne, D.O.
Lawrence K. Loo, M.D.
Franz Fisher, M.D.
Loma Linda University School of Medicine, Loma Linda, CA 923541
Dorfman L ,Schauffler HH ,Wilkerson J ,Feinson J . Local television news coverage of President Clinton's introduction of the Health Security Act. JAMA 1996;275:1201-1205
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Author/Editor Response
The authors reply:
To the Editor: All these letter writers suggest, and we agree, that television influences the public in powerful ways and that it systematically misrepresents medical reality. The argument, as articulated by Baer, Borowsky, and Wootton, comes down to one crucial question: Are television's misrepresentations necessary for dramatic effect? We think not. Instead, we think it would be possible to portray medical reality more accurately without sacrificing drama.
We encourage television writers to explore dramatic possibilities that do not rely on overly optimistic presentations of medical outcomes. Imagine a program about a six-month-old baby brought to the emergency room apneic and pulseless. A vigorous resuscitation restores heartbeat and circulation, but the baby's pupils are fixed and dilated. A heated discussion ensues among the doctors and family about futile treatment, criteria for brain death, and the possibility of organ donation. Or, a 79-year-old man is brought to the emergency room from a nursing home with suspected urosepsis. He seems to have dementia, but little history is available. No family member can be reached. He is rapidly decompensating. The physicians debate whether to intubate. Such stories, we believe, could be made compelling. By portraying a background rate of survival after resuscitation efforts that approximates reality, the “saves” would be made more dramatic and the demands on the television doctors more challenging.
The issue, we think, is not whether such scenarios could be presented in a compelling way. It is whether television writers are going to grapple with the really tough dilemmas and choices facing doctors and patients today.
Finally, Mulcahy et al. remind us that the medical community bears some responsibility for the public's expectations of medicine. Therefore, physicians bear that much more responsibility to counter the inaccurate images portrayed on television and to educate patients and families about the risks and benefits of CPR.
Susan J. Diem, M.D., M.P.H.
Durham Veterans Affairs Medical Center, Durham, NC 27705John D. Lantos, M.D.
University of Chicago, Chicago, IL 60637James A. Tulsky, M.D.
Duke University Medical Center, Durham, NC 27710- Citing Articles (1)
Citing Articles
1
R.M. STRAUSS, H. MARZO-ORTEGA. (2002) TV medical dramas ??? British or American: which approach do you prefer?. European Journal of Emergency Medicine 9:2, 183
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