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There is nothing wrong with your television set. Do not attempt to adjust the picture. We, the AMA, are controlling transmission.

September 2005 -- Late this month, Slate posted a piece by two Boston medical residents (and clinical fellows at Harvard) entitled "Paging Dr. Welby: The medical sins of Grey's Anatomy." Authors Ingrid Katz and Alexi Wright make some good points about the ABC hit's medical inaccuracies and distortions. But their main theme seems to be that things would be better if the American Medical Association had never lost its tight control over how physicians and presumably all health care events are portrayed, which has supposedly led to unsavory depictions of physicians as deeply flawed humans, rather than the godlike Welbys of yesteryear. This, along with medical inaccuracies generally, assertedly works to undermine vital public trust in physicians. Evidently, the authors would entrust public understanding of health care errors, health financing, scope of practice, access to care, and health policy generally to a lobbying organization representing a small minority of powerful health workers who lack expertise in many key areas of modern health care. The authors also overlook the media's ongoing portrayal of physicians as the heroic (if human) providers of all important health care. And they ignore the enormous influence individual physicians--like them--continue to wield over such depictions, influence that has, sadly, been a significant factor in the ongoing representation of nurses as peripheral subordinates who make no meaningful contribution to health care.

Katz and Wright argue that "Grey' Anatomy" is not just silly, but (like Fox's "House") is also medically misleading and unconcerned with patients. They suggest that it was not always this way. In the 1960's, they write, shows like "Ben Casey" and "Marcus Welby, MD" focused on the bedside, and this was because "doctors had a surprising degree of control over their TV image. However self-servingly, they nudged producers to paint a clearer, better picture of medicine than today's shows." The authors, apparently relying on Joseph Turow's "Playing Doctor: Television, Story Telling, and Medical Power," tell how the AMA asserted control over network television shows in the 1950's and 1960's, actually winning the right to vet scripts. AMA personnel acted as "hawks for medical accuracy," while ensuring that physician characters generally made no errors, never got sued, and lived virtuous lives. While the physicians were "one-dimensional superheroes," the shows focused closely on the real problems of patients, such as child abuse.

But then the 1960's and a show called "The Nurses" arrived to destroy this golden age of medical accuracy. It seems that that show's producer actually "refused to hire AMA vetters, instead employing a nurse to ensure medical accuracy." (No doubt we're supposed to think: Can you imagine? A nurse! No wonder the show flopped!) This supposedly ended the AMA's "hegemony," and in the 1970's, "M*A*S*H" blew everything to hell "by treating doctors with utter irreverence," as physicians drank, chased nurses, and so on. The ensuing decades brought shows with scripts oriented around physicians, rather than patients. Sure, "St. Elsewhere" and "ER" got credit for showing tough urban care environments and running "controversial" story lines, but "the shows filtered every experience through the eyes of a doctor or nurse. Unlike their godlike predecessors, the physicians on these series were pathetically human, battling drug addictions, health problems, and bad relationships." Horrors! Physicians as real people under great stress? How can we build a health care system on the truth?

"Grey's Anatomy" is the "extreme" culmination of this genre, the authors argue, as the physician characters sleep with each other, nurses, and patients. The medical inaccuracies are worse. An irresponsible plotline involving an illegal autopsy reminded the authors of the Tuskegee experiments, and they argue, persuasively, that the grossly inaccurate one about organ donation could discourage such donations. The authors assure us that they don't miss Dr. Welby's "starched white coat," but that episodes like these make them "long, in spite of ourselves, for the days when the AMA had television producers on a tighter leash...[W]e are afraid that TV's worst inaccuracies may compromise what trust remains between doctors and patients."

We agree with Katz and Wright that the media affects what people think and do with regard to health care, and that distortions like those they mention can be damaging. Indeed, though it's not clear if the authors are aware of it, public health research shows that such entertainment programming does have a real world effect. We also agree that "Grey's Anatomy" and "House" have offered damaging distortions on a number of health issues. We might even agree that presenting physicians as irresponsible sex maniacs could undermine patient trust, if we thought that a show was actually presenting the characters as negative, which for the most part these shows are not. Perhaps we and the authors see the "Grey's Anatomy" physicians as idiots, but it seems safe to say that the show's 20 million viewers do not. Of course, many television dramas portray characters this way, and whatever the authors may think, the oversexed physician is not a widespread social stereotype. The audience is meant to hold the physicians in awe, not contempt.

More broadly, the authors (despite acknowledging the self-serving aspects of the former AMA role) seem eager to return us to an era of blind trust in organized medicine. Shows like "ER," many of whose episodes are actually written by physicians, may be gritty and "controversial," but apparently they're no substitute for a paternalistic enforcer from the medical elite. The authors may not realize it, but the loss of AMA's direct hegemony was not the result of the decision of one misguided producer who actually thought nurses could be trusted, but more likely part of the huge social changes wrought by the civil rights era, the upheavals of the 1960's, and Watergate, a period in which the public became more willing to question institutional power, and less willing to place blind trust in authority figures. It may be tempting to pine for the "good old days," but of course, in those good old days it is unlikely that the female author of this article would have been able to become a physician at all. The change since those days is probably less due to the work of the AMA than those who embraced media products like "M*A*S*H," which asked viewers to question the established order and do what they could to improve it by telling the full truth, rather than some sanitized version calculated to conceal wrongdoing and preserve an unjust status quo. Indeed, many believe that social and scientific progress is impossible in an environment of rigid central control of information.

Moreover, it is almost funny to read a piece by members of the professional group that enjoys more economic and social power than any other complaining that the media is not treating them well enough. Perhaps those who really do expect to be portrayed as flawless heroes have a hard time being seen as flawed heroes. But the fact is that every major health care show of the last 10 years has treated physicians as the glorious providers of all significant care, smart, brave, and in many contexts omniscient. Physician characters in these shows have persistently been shown performing key care tasks that other professionals (nurses, social workers, physical therapists, etc.) really do. Physician characters may do things real physicians disapprove of, but they are still presented to the public as life-saving heroes. Meredith Grey is not perceived as a ditzy, vacuous slut, but a smart, attractive young physician who's going places. And the senior physicians on such shows are pretty close to God in their authoritative actions and declarations. So while we agree that shows like "Grey's Anatomy" affect what people think, we can't agree that they're causing harm by making the public think physicians are immoral idiots who can't be trusted.

Moreover, individual physicians continue to exert significant influence on the media that does appear, and they are the overwhelming choice as health experts for news sources and advisors to Hollywood shows. A number of physicians have actually been among the main writers of hospital shows, notably "ER." Physicians utterly dominate the media's depiction of health issues, and in fact, an argument can be made that this domination has contributed to the media's deferential treatment of physicians' complaints about malpractice costs and other issues. In entertainment shows, physician characters do make mistakes (almost always the junior ones), but they are rarely presented as motivated mainly by ego or economic concerns, as failing to listen to patients or colleagues, as pursuing a questionable care model, or as supporting policies that reduce public access to care. "ER" is forgiving of physicians in many respects, but if it had to run its scripts past the AMA, we wonder if it would have run episodes questioning current health care financing systems or the actions of large drug companies. And given the AMA's persistent efforts to limit and undermine the practice of nurse practitioners, we can only guess what a Hollywood that had to run its scripts past the AMA would have to say about NPs.

In fact, the physician-dominated Hollywood shows have been a disaster for nursing, portraying nurses as peripheral subordinates to the commanding physicians who provide all significant care. Physicians are regularly shown doing key care tasks that nurses do in real life, and today, roughly 24 of 25 major characters on the three leading prime time shows are physicians. The physician-centric vision of health care is a significant factor in the global nursing crisis. To make the vision of Hollywood even more narrow through AMA control would be a disaster. For one thing, the authors seem to assume that the shows they're discussing only affect physicians, or perhaps that the only thing that matters is how they affect physicians. Of course the shows generally pretend that only physicians matter, but the fact is they are presenting viewers with a vision of hospital care generally, care which in real life is provided by a diverse team of which physicians comprise a small, if powerful, minority. In addition, the AMA is not expert in nursing, social work, or a number of other fields. The authors also seem to assume that the interests of organized medicine are synonymous with those of patients and society in general. But no group should have total control of how it is depicted in the media. What would the authors say if the police claimed the right to vet all crime-related shows? Or the ABA to vet all legal shows?

Whatever the faults of the nursing portrayals on the seminal "M*A*S*H" or "ER," to suggest that the paternalistic, surreally positive "Marcus Welby" presented a "better" overall vision of care is very dubious. Indeed, as the Center has noted, some physicians felt "Welby" was so positive it created unrealistic expectations, making real physicians suffer by comparison. Today's more naturalistic physician hero may not raise this problem to that extent (see, e.g., "House"), though of course you could argue recent shows create expectations that physicians will actually spend hours with each patient. Physicians seem to be weathering that distortion.

In fact, the Welby-type portrayals were not just unrealistically positive. They suggested that physicians did everything of importance, including nursing. Extensive research done in the 1980's by nursing scholars Beatrice and Philip Kalisch (Bea Kalisch is the Center's board chair) found that television shows presented omniscient physicians doing the work of other health professionals to such an extent that they dubbed the phenomenon the "Marcus Welby Syndrome." Obviously, this distortion has damaged nursing and other health professions. No profession should get credit for the work that another does. Such portrayals have influenced the way health decision makers think, and helped to drive the endemic underfunding of nursing. Today, a global nursing crisis is killing thousands. The physician-centric Welby vision offers little to those patients.

Of course, we have many problems with the way "ER" and the other modern health care shows depict nursing. But the answer is not to turn back the clock to some illusory golden age dominated by a paternalistic overseer, in which there would be even less chance that the truth about nursing or other vital health care issues would emerge. We wish Hollywood would seek our input on scripts and show some of the real nursing role. But we would never claim the right to have exclusive control of everything the mass media presents to the public about health care. To make that claim would seem to require a special vision of your place in the health care world.

See the Slate article: "Paging Dr. Welby: The medical sins of Grey's Anatomy" by Ingrid Katz and Alexi Wright.

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