From Dr. Kildare to Grey's Anatomy:
TV Physicians Change Real Patient Expectations
Article Outline
It's been little more than a year since the longest-running primetime medical drama in American television history, ER, wrapped on NBC in April 2009. At its commercial peak, 25 million viewers tuned into ER weekly to track the doings of physicians and nurses at fictional County General Hospital in Chicago, bringing with mixed realism the drama of the emergency department (ED) into people's homes. The critically acclaimed show's 15-year run spanned a period during which medical dramas changed substantially, completing a transformation from straight-laced, wholesome physicians in the 1960s and 1970s, such as Marcus Welby, MD, to the libido-enhanced physicians on today's most popular medical drama, Grey's Anatomy.
With ER's end, and popular medical shows such as Grey's Anatomy continuing to push the boundaries of television, it is natural to ask how the changing way in which television portrays physicians might color the public perception. And more to the point for emergency physicians, who may only have a few minutes to establish a rapport with patients whom they must persuade to follow specific discharge instructions, might television's worst inaccuracies compromise what trust remains? “I worry about it,” said Ingrid Katz, MD, an associate physician in the Department of Medicine at Brigham and Women's Hospital and an instructor in medicine at Harvard Medical School. “When I speak with people who aren't physicians, I find that they certainly have a somewhat skewed perception of what we do during our daily lives based upon what they see in the media. It's not a hyperhormonal lovefest they see on a TV show.”
The traditional physician-show formula became solidly entrenched during the middle of the 20th century, first with Dr. James Kildare in films and later on television (1961 to 1966) and Ben Casey (also 1961 to 1966). The essential idea of these shows, which sought and received creative input and guidance from the American Medical Association, was that physicians were a kind of elect; they were either born physicians or had the innate skills to become one. In most television portrayals, physicians worked in hospitals, dealt with acute conditions, were the captains of the medical enterprise, and had unlimited resources. And, critically, physicians in such shows were often not the central focus of storylines, but rather conduits for finding out more information about patients, around whom the plots revolved. “Very often the doctor was a continuing character, while the real focus was on the patient or patients each week, who had physical and emotional problems that usually would be resolved by the hour's end,” said Joseph Turow, PhD, the Robert Lewis Shayon Professor of Communication at the University of Pennsylvania's Annenberg School for Communication. A new and expanded version of Dr. Turow's 1989 book Playing Doctor: Television, Storytelling, and Medical Power, will be published later this summer.
These medical dramas in the 1960s and 1970s played out even as the medical system underwent enormous change with an aging population, demonstrating that unlimited medical resources could not be applied to all patients and that chronic problems were as serious as acute ones, and demonstrating the increase of insurance issues and managed care. These were topics that rarely appeared in televised dramas.
Physician Reveal Thyself
Although television shows were ignoring these changes, they were substantially repositioning the role of physicians in medical dramas, Dr. Turow said. Beginning with M*A*S*H, which first aired on television in 1972 and ran until 1983, the focus shifted from patients to the physicians, and for the first time viewers began to get more information about physicians and their lives than the patients. The trend continued with St. Elsewhere (1982 to 1988), ER, and other medical dramas in the 1990s. Today's television shows will often encapsulate a patient's problems in a 5-minute vignette that would have filled an hour-long show in the 1960s. “Television producers were trying to reach more people, particularly women, by identifying with angst and romantic sensibilities of doctors,” Dr. Turow said.
As this shift was happening, Rebecca Chory, PhD, now an associate professor of communication at West Virginia University, began studying the effect of such portrayals on patients' attitudes toward physicians. Using a survey of 300 undergraduate students, she compared perceptions of physicians in 1992—the end of the era when physicians were shown as all-knowing, wise father figures—with those in 1999, when shows such as ER and Chicago Hope (1994 to 2000) were continuing the transformation to showing the private side and lives of physicians, including vivid demonstrations of their weaknesses and insecurities.
Dr. Chory found that, regardless of the respondents' personal experiences with physicians, those who watched certain kinds of television had declining perceptions of physicians' composure and regard for others. Her results indicated that the more primetime physician shows that people watched in which physicians were the main characters, the more uncaring, cold, and unfriendly the respondents thought physicians were. “It's not as if people thought doctors were horrible people,” Dr. Chory said. “The effect wasn't superstrong, but there was still a relationship there that wasn't due to chance. And it makes sense. Those TV shows showed doctors not always on their best behaviors.”
Dr. Chory also found that when people watched more prime time nonmedical dramas, such as crime and courtroom shows, they also believed physicians to be less competent. She believes this is because, in such shows, physicians were often portrayed as criminals or having committed malpractice. Physicians were rarely shown in a flattering light. Finally, her research indicated that if people more commonly watched news magazines such as 48 Hours rather than medical dramas, they were more apt to believe physicians were more competent.
Dr. Chory's research did not extend to causality, and there have been no definitive studies that prove TV medical dramas have materially altered, for better or worse, the public perception of physicians. “To my knowledge of other scholars, no one has looked at all of these variables—what we watch, what we think about it, and how that translates into actions—in a single study,” she said. “Another concern, something that also hasn't been fully studied, is the CSI effect. Juries today expect DNA evidence and unbelievable proof in real-life cases like they see on TV. In the real world that doesn't happen. With physicians they may expect a miracle cure, or a good-looking doctor, or someone who even when you're at death's door is going to come up with a cure. With such expectations raised, people can have less satisfaction when reality is less glamorous. Or they might be more likely to sue.”
In the decade since Dr. Chory conducted her research, the nature of medical dramas has continued to change, most notably with the premiere of Grey's Anatomy (2005 to present), which at its commercial peak regularly attracted nearly 20 million viewers each week. The show has pushed sex in the hospital to new heights. The show's very first episode focused on Meredith Grey (Ellen Pompeo), a new surgical resident at the fictional Seattle Grace Hospital, discovering the next day that a stranger she had a one-night stand with was her new boss, Derek Shepherd (Patrick Dempsey). During a more recent episode, Grey was drafted to help a pediatric surgeon (Grey's boyfriend's wife) to operate on a pregnant woman (who lost her husband to an affair). And so the bottle spins in the Seattle hospital.
Art Imitating Life
Anne Gross, MD, a graduate assistant and clinical/research fellow at Massachusetts General Hospital, Harvard Medical School, said she and her colleagues began discussing these kinds of behavior by television physicians, as well as other trends they perceived in TV dramas, such as the appearance of hospitals as busier places in which physicians were less likely to sit down and talk with their patients or to establish a rapport. Dr. Gross and her colleagues wondered if this was art imitating life or not. Like other researchers, they were also keenly interested and concerned about how such shows might be changing public perceptions of physicians.
Her group studied behavioral changes in 4 different shows, from St. Elsewhere and ER to Scrubs (2001 to 2010) and Grey's Anatomy. They looked at fourth and fifth episodes in the first season of each shows, when screenwriters were believed to be focused on character development. Dr. Gross and her colleagues looked at a number of variables, such as how often physicians discussed news with patients sitting versus standing.
Over time, the group found, sitting while delivering medical news has decreased, indicating a decrease in the rapport between patients and physicians. Additionally, whereas raised voices were once rare and to subordinates only, in the modern shows it increased in frequency and was increasingly performed by female physicians and toward supervisors, as well as subordinates and peers. Finally, and most disturbingly, inappropriate touching was largely absent until Grey's Anatomy, during which it was done by male physicians toward subordinates and female physicians toward supervisors. “It was just a small review, and this raises more questions than it answers,” Dr. Gross said. “Whether this impacts patients will require more study.”
Brave, Heroic, Libidinous
The notion of studying how medical shows change patient attitudes did not occur to Brian Quick, PhD, a University of Illinois at Urbana-Champaign assistant professor of communication, until he heard his students buzzing about Grey's Anatomy. As it turned out, many students delayed or even avoided going out with friends to watch the show when it aired. Quick was interested in using the show as a test of cultivation theory, which suggests that over time the more people watch television, the more likely the views and beliefs portrayed on television begin to affect peoples' perceptions. Quick surveyed 269 students and validated the theory for Grey's Anatomy. “I'm confident that heavy viewing of any medical drama is going to impact peoples' perceptions of real world doctors, particularly if they believe the show is credible,” he said. “And the more people watch these shows, the more likely people are to believe they are indeed credible. This goes back to cultivation theory.”
But unlike some other researchers, Quick did not find that watching Grey's Anatomy and its surgically talented but psychologically flawed physicians had a negative effect on patient perceptions of physicians. Specifically, the relationship he found was that the more people watched the show, the more realistic they thought it was; the more realistic they thought it was, the more likely they were to perceive actual physicians as courageous, brave, heroic, clever or brilliant.
Quick notes that he sampled students, so the study does not necessarily apply to the entire population. And the study did not look specifically for associations between viewing Grey's Anatomy and negative perceptions of physicians.
Dr. Turow said he nonetheless remains concerned about public trust in physicians. The disconnection between medical dramas and the real world of medicine—insurance, limited funds, long wait times—he believes, very likely will have negative effects on patient perceptions. Dr. Turow also worries that TV viewers who buy into dramas as reality will look behind the scenes of medicine and see a bunch of bickering physicians who are waylaid by their own psychological problems. “I think what this does, is get people really nervous about medicine today,” he said.
How much medical dramas really do this, and indeed regardless of how far TV shows actually go toward changing patient perceptions of physicians, Dr. Turow believes physicians should be paying attention to what's on TV. When patients come into an ED or physician's office, many will have preconceived notions about what to expect from their physician and his or her ED after watching ER or Grey's Anatomy.
Physicians should therefore be cognizant of such perceptions and take care to help patients understand why their case may not be resolved quickly, why time moves slower in actual hospitals than on television, and about the dynamics of a team approach to medicine rather than a TV physician captaining the ship from the initial point of care to discharge. If not, a patient may be disappointed when George Clooney does not magically appear to save the day.
PII: S0196-0644(10)01250-3
doi:10.1016/j.annemergmed.2010.07.020
