STUDENT LIFE
How true to life are medical dramas?
Medical dramas are among the most popular shows on television. In the United States the programme er attracts more viewers than any other drama series on television. The interest in medical dramas started with Dr Kildare in the 195Os - a young handsome intern in an American teaching hospital who frequently made nurses swoon with his sweet and sincere bedside manner.
Doctors continued to be portrayed as pure and heroic until the American series MASH, set in South Korea. In MASH doctors wisecracked about their patients, drank heavily, talked cynically, and had casual sex. Every so often a patient even died. Viewers suddenly saw an image of medicine that was slightly more fallible and therefore more true to life only considerably funnier. Now we have Casualty, Chicago Hope, ER, Cardiac Arrest (the most realistic and blackest of the dramas - and currently under threat of being dropped), and series set in general practice such as Peak Practice. Some are more authentic than others - but all combine life threatening drama with the traumas of relationships.
Even though television schedules are cluttered with medical dramas, all have viewing figures that television executives would kill for. In Britain Casualty is the most popular with roughly 15 million viewers per episode, followed by Chicago Hope with 8 million, Cardiac Arrest with 6 million, and ER with 4 million.
Viewers enjoy medical dramas because they can watch life and death situations without their own health being at risk. There is also an enormous interest in modern medicine and it's potential for curing the most desperate of diseases.
How are they written?
Medical dramas usually have doctors involved in writing the scripts. ER, for example, is written by a team of six writers, including two practising emergency doctors, who collaborate in the planning of storylines for the seven principal characters. Many of the stories are inspired by the experiences of practising doctors and nurses and illustrate the character's struggles with ethical issues or personal problems. For example, in one episode Carter, a medical student, inadvertently injures a patient while performing a thoracentesis. His first reaction is fear that he will not be selected for the residency of his choice rather than concern about the patient. It shows how a medical student can lose sight of the primary goal of patient care in a competitive environment. The completed script is then vetted by a technical advisor, trained in emergency and internal medicine, who resolves any disagreements about treatment or diagnosis.
Drs Ross and Green from ER saving another Patient
An important part of the attraction of these programmes is their realism,(1) but to keep the dramatic interest the line between fact and fiction is smudged. Real life in an emergency room is quiet and often boring. In a 12 hour shift, perhaps only half an hour is really as frantic as one episode of a medical drama. Medical dramas serve up a form of condensed medicine so that procedures are performed faster and more simplistically than in real life, although the treatment does reflect a good standard of care.
Illusions
The cast of Casualty
Medical dramas can encourage people to become doctors. It was Casualty that inspired John MacUre to become a doctor, although after experiencing the harsh reality of ward life, he turned his back on medicine and penned Cardiac Arrest in the hope that it would give a truer representation of medicine. In Cardiac Arrest doctors have blood shot eyes, are sloppily dressed and use colourful language.
When I first entered a real ward, after being brought up on a diet of medical dramas, I noticed three striking differences. Firstly, the large number of old people on the ward. Where were all the young, attractive patients? Secondly, none of the patients in Casualty seem to have that ghastly, ghostly pallor. And finally, there are nurses and doctors who are more plain than glamorous. Presumably medical dramas need sex to boost audience figures.
What is portrayed on screen shapes our understanding of medicine, illness, and death.(2) The danger is that these perceptions could cause patients to make ill informed decisions about their treatment and at worst cause them to overestimate their chances of survival.
| Doug Ross, ER |
| Where Dr Green is the balding 2.4 children type, Dr Ross is the modern day Casanova, who attracts beautiful women. This dashing doctor has coined a look that is totally his own - his head bowed looking up past his eyebrows. He's an ultimate insult to political correctness having slept with both his father's lover and a medical student. However, he regularly rescues himself in the viewing public's eye through selfless acts of humility fuelled by his position as a paediatrician. His colleagues are tolerant of his behaviour in view of his troubled childhood and underlying insecurities.
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| Andrew Collins, Cardiac Arrest |
| Dr Collins started out as a terrified house officer who cared about his patients. He was a dutiful doctor, husband, and friend, but soon strayed from the straight and narrow. In the last episode of the series, Dr Collins was told by his lover that she was pregnant and ended the day being attacked with a needle and syringe full of insulin. The ensuing drama depicted Dr Collins pale and sweaty, reciting the correct therapy for insulin overdose in an attempt to stay awake while his colleagues prepared the necessary glucagon, glucose, and potassium. With a touch of artistic license, the closing scene is one of the on call surgeon getting ready to excise a chunk of Dr Collins' thigh the site of the injection.
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Misinformation
Cardiopulmonary resuscitation is an essential component of all medical dramas. The patients are often young and attractive and after much shouting, bleeping, and chaos, the doctors usually bring them back to life. Resuscitation provides much dramatic impact and visual excitement, but it distorts the public's view of the procedure. A recent study looked at the depiction of cardiopulmonary arrest in whole series of three popular American medical dramas - ER, Chicago Hope, and Rescue 911 (which shows re-enactments of actual rescues by the emergency services in the United States).(3) The study found that the programmes over represent cardiac events requiring resuscitation in children, adolescents, and young people. Young people represented 65% of those given cardiopulmonary resuscitation in the programmes, whereas in reality cardiac arrests are much more common in elderly people. Most cardiac arrests in the dramas resulted from gunshot wounds and road accidents - only 28% were due to cardiac disease, although 75-95% of cardiac arrests in the United States are due to cardiac disease.(4-5)
Perhaps the most important misrepresentation, however, is the overestimation of the success of cardiopulmonary resuscitation. In the programmes 75% survived the immediate arrest and 67% appeared to have survived hospital discharge. These rates are much higher than those reported in medical literature. The outcome of resuscitation is also portrayed as cut and dry full recovery or death. But in fact many of those who survive cardiac arrest have some disability.(7) Out of 97 arrests shown on television, only one survivor had a disability.
The positive way in which programmes portray cardiopulmonary resuscitation affects the public's perception of reality, as most patients learn about it from television. This means than people overestimate their chances of survival after resuscitation.(8-10) The problems of resuscitation are sometimes discussed. For instance in one episode of ER doctors discussed the possibility that a child with hypothermia might sustain neurological damage after resuscitation. But these discussions are few and far between and are outweighed by the visual power of the procedure.
Medical dramas may also encourage us to believe in miracles. For instance, in Rescue 911 doctors often predict poor outcomes for patients, while family members voice their hope and then their joy at the "miracle" of their loved ones recovery. Such scenes could encourage the public to hope for miracles. Although faith is central to maintain hope, belief in miracles can lead to decisions that can harm the patient and undermine their trust in doctors.
What should the medical profession do?
We cannot let the blame rest solely on medical dramas for failing to be true to life. The fact that most patients learn about cardiopulmonary resuscitation from television suggests that doctors are partly to blame for not providing their patients with the information necessary to make critical decisions. Studies have shown that doctors are reluctant to discuss the final wishes of their patients(11) even though patients prefer these discussions to be initiated by the doctor.(12) Doctors need to make a concerted effort to discuss this difficult issue with all their patients, asking about patients' perceptions of survival and addressing the images on television. This will enable doctors, patients, and families to make better informed decisions and lessen the importance of reality in medical dramas.
I thank Shamina Ahmed for her advice.
Debashis Singh,
first year preclinical student,
University of Leicester,
Leicester LE1 7RH
REFerENCES
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2 Throw J. Playing doctor: television, storytelling, and medical power. New York: Oxford University Press, 1989.
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4 Rott R, Stewart R D, Rogers K, Cannon G M. Out-of-hospital cardiac arrest factors associated with survival. Ann Emerg Med 1984;13:237-43.
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7 Edgren B, Hedstrand U, Kelsey S, Sutton-Tyrrell K, Safar P. Assessment of neurological prognosis in comatose survivors of cardiac arrest; BRCT 1 Study Group. Lancet, 1994;343:1055-9.
8 Schonwetter R S, Walker R M, Kramer D R, Robinson B E. Resuscitation decision making in the elderly: the value of outcome data. J Gen Intern Med 1993;8:295-300.
9 Schonwetter R S, Teasdale T A, Taffet G, Robinson B E, Lachi R J. Educating the elderly: cardiopulmonary resuscitation decisions before and after intervention. J Am Geriatr Soc 1991;39:372-7.
10 Murphy D J, Burrows D, Santilli S, Kemp A W, Tenner S, Kreling B, et al The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med 1994;330:545-9.
11 BedeIl S E, Delbanco T I. Choices about cardiopulmonary resuscitation in the hospital: when do physicians talk with patients? N EngI J Med
1984;310:1080-93.
12 Morrison R S, Morrison E W; Glickenan D R. Physician reluctance to discuss advance directives: an empiric investigation of potential barriers. Arch Intern Med 1994;154:2311-8.