The Hot Spotters

Can we lower medical costs by giving the neediest patients better care? BY ATUL GAWANDE I f Camden, New Jersey, becomes the first American community to lower its medical costs, it will have a murder to thank. At nine-fifty on a February night in 2001, a twenty-two-year-old black man was shot while driving his Ford Tau-rus station wagon through a neighborhood on the edge of the Rutgers University campus. The victim lay motionless in the street beside the open door on the driver's side, as if the car had ejected him. A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back. " He's not going to make it, " an officer reportedly told the physical therapist. " He's pretty much dead. " She called a physician, Jeffrey Brenner, who lived a few doors up the street, and he ran to the scene with a stethoscope and a pocket ventilation mask. After some discussion, the police let him enter the crime scene and attend to the victim. Witnesses told the local newspaper that he was the first person to lay hands on the man. " He was slightly overweight, turned on his side, " Brenner recalls. There was glass everywhere. Although the victim had been shot several times and many minutes had passed, his body felt warm. Brenner checked his neck for a carotid pulse. The man was alive. Brenner began the chest compressions and rescue breathing that should have been started long before. But the young man, who turned out to be a Rutgers student, died soon afterward. The incident became a local scandal. The student's injuries may not have been survivable, but the police couldn't have known that. After the ambulance came, Brenner confronted one of the officers to ask why they hadn't tried to rescue him. " We didn't want to dislodge the bullet , " he recalls the policeman saying. It was a ridiculous answer, a brushoff, and Brenner couldn't let it go. He was thirty-one years old at the time, a skinny, thick-bearded, soft-spoken family physician who had grown up in a bedroom suburb of Philadelphia. As a medical student at Robert Wood John-son Medical School, in Piscataway, he had planned to become a neuroscientist. But he volunteered once a week in a free primary-care clinic for poor immigrants, and he found the work …