AMA Journal of Ethics^®

Perry Mason and the district attorneys from Law and Order are probably society's most recognizable lawyers. Similarly, shows from Dragnet to NYPD Blue have defined the image of a detective. Inevitably these pervasive images blur the lines between fiction and reality in a given profession. The same is true with medicine, but with one major difference: although a majority of the general public will never be in the criminal situations and legal predicaments dramatized by the entertainment industry, almost all viewers will be patients at some point. And what the public sees affects what they think about physicians. That is the warning we were all given at our white coat ceremonies. You might not have noticed it, but it was there in the form of a shrink-wrapped DVD attached to the back of the book, On Doctoring. That video presentation casts the medical drama in a new light.

The DVD is entitled, Prime Time Doctors: Why Should You Care? Its writers, Joseph Turow and Michael Serazio, comment on excerpts from some of the most popular medical television shows and movies of the past 75 years, and they tell us early on that, "The patients you meet in coming years may have doubts about you because of the doctors they see on prime time television"[1]. This statement sets the tone for the remainder of the presentation, which tackles episodes of medical uncertainty and describes ethically complex story lines that patients have seen portrayed by tinsel-town doctors and have come to believe about their real physicians.

The presentation encourages medical students and physicians to be self-reflective and question how much they too have been influenced by television. Traditionally, medical dramas have exalted the physician as a noble warrior who uses his intelligence and skill to defend the most vulnerable against the calamity of disease. When this idealistic notion is combined with George Clooney or Patrick Dempsey as the popular face of medicine, who wouldn't want to be the next Dr. Ross or Shepard? We might be reluctant to admit that television played a role in our career choice, but it is undeniable that these shows have helped shape society's opinion of physicians. Now when we watch, we can distinguish fact from fiction because of our medical training. But most patients do not have that opportunity, a fact that might create hurdles for budding physicians.

Turow and Serazio explain that the need for gripping drama has transformed the television physician from an infallible superhero to an imperfect human plagued by uncertainty and peril. In the era of Doctor Kildare (1961-1966), TV physicians faced problems that were practical and methodically solved. As Turow and Serazio say, "In the early decades of movies and TV, doctor shows were filled with tales of scientific progress and moral clarity" [1]. An episode's story line was smooth, reliable and reassuring but rather bland by modern standards. The writers of today's shows weave plots with complex ethical dilemmas and procedural mishaps that seem to prove Murphy's Law. As the authors state,

Today we see new themes in how Hollywood is portraying doctors, hospitals and the world of medicine. They are drawn from issues of power, fallibility, and, most of all, controversy. They highlight doctors' shortcomings as practitioners and as human beings [1].

One study found that in the 1996-1997 season of ER physicians spent as much screen time dealing with personal issues as treating patients [2]. More than 50 percent of the plots were found to involve dilemmas of professionalism and ethics. This study also found that the two most popular personality traits of physicians were sensitivity and vulnerability [2]. Portraying physicians as human beings—rather than the gods they once were on television—leaves a much different impression with patients [1].

Complex ethical dilemmas are probably the most consistent theme in all current medical dramas. Turow and Serazio point out that, "In popular culture today, medical certainty can no longer be taken for granted" [1]. Prime Time Doctors highlights, for example, an episode of ER in which Dr. Benton has to decide whether or not to perform surgery on a patient who would rather die than have the operation [1]. On TV, the physicians who make these decisions appear to be on an island, where they alone shoulder the burden of the choice. Rarely do we see how such ethical decisions are actually made—through ethics committee meetings and consultation with the patient's family and, if necessary, hospital administration. Early in medical training, students are asked to solve fictional ethical dilemmas. To help us with the task, we are introduced to decision-making models, protocols and guidelines that consider all of the parties involved. These tools allow us to weigh the effects each option will have on each party and bring clarity to a process that could otherwise become far more confusing.

In the same manner, hospitals and other health care institutions have protocols and guidelines that physicians can follow when faced with a quandary. Hospital ethics committees staffed with bioethicists, lawyers and physicians handle especially difficult problems not explicitly covered by the guidelines. But showcasing a room full of experts deliberating ethical dilemmas or explaining the systems and institutional protocols detracts from the drama and mystery that television audiences demand. It is intentional that "the world of TV medicine is not as straightforward as it once was" [1]. Future physicians must realize that, while we will undoubtedly face our share of ethical dilemmas, there are systems in place to get us through. Unlike Dr. Benton, we are not on an island.

By creating awareness of the controversial images of medicine, Prime Time Doctors overlooks some of the potential good that comes from the television shows. The fact that millions of people eagerly await their weekly dose of medical suspense is a testament to the outreach potential these dramas have. A study published in the British Journal of Medicine found that the information broadcast on these shows can have a significant impact on the actions and attitudes of the audience [3]. After an episode about a paracetamol overdose aired, viewers were twice questioned about the facts of an overdose, first one week after the show aired and then 31 weeks later. The results were compared with responses from people who had not watched the show. The study discovered that those who had watched the show were much more aware of the signs of a paracetamol overdose and were significantly more likely to seek help in the case of one [3]. Similarly, viewers of Amarte Asi, a telenovela on the Telemundo network in which one of the protagonists has diabetes, were more likely to be knowledgeable about the disease and to exercise and eat more healthful foods than nonviewers [4].

The federal government recognizes the ability these shows have to disseminate information to a large group of people. The Centers for Disease Control (CDC) has contacted TV executives on many occasions, asking them to incorporate public health messages into their shows [4]. Subjects that are often not discussed like HIV/AIDS and organ donation are worked into a story line to help educate the public [4]. The type of exposure that the CDC's initiative gets in exchange for sharing their medical expertise with a show's writers is quite astonishing. During the 2005 season of Grey's Anatomy, a 30-second ad cost more than $350,000, while an hour-long episode devoted to a CDC-endorsed public health matter was free [4].

The principle that patients' interest comes first is the foundation of medical ethics and the point that Prime Time Doctors leaves us with.

The messages prime time TV offers about physicians are not always comforting ones. But patients may also carry in their heads one consistent message that may benefit you greatly. It is that despite personal and professional troubles, despite the bureaucratic roadblocks…DOCTORS DO CARE [1].

It is not uncommon for a television episode to depict a physician jeopardizing his or her career and respect from colleagues to accomplish something that will benefit the patient. The authors urge their audience to capitalize on the widely held belief that despite all their shortcomings doctors still care about their patients. This longstanding truth can serve as a foundation from which to build trust and rapport between patient and physician in an age where what is real and what is fiction becomes more indistinguishable every day.