Kill Your Television.

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I don’t watch much television (as a matter of fact, one of my favorite gadgets that I’ve acquired is the TV-B-Gone (it’s a great way to make a hospital room quiet on rounds). It’s not that I don’t like television. I do. It’s mindless relaxation that is semi-informative, occasionally funny, and once-in-a-while, entertaining. I will admit to having been captivated by Homicide: Life on the Streets, Twin Peaks, M*A*S*H, and most recently by Lost.

I never liked, with the exception of M*A*S*H, and perhaps St. Elsewhere, medical television shows. Medicine is exciting and dramatic, but most shows like ER and House pack more psychodrama, trauma, and tension into an hour than I’ll get in my worst month. There is also the medical “unreality” of these shows that was first documented in a terrific article in the New England Journal of Medicine entitled, Cardiopulmonary Resuscitation on Television – Miracles and Misinformation. This paper looked at the shows ER, Chicago Hope, and Rescue 911 and compared the outcomes from CPR on the show versus data from real life. Their discussion (which you can read in its entirety here [note: .pdf file]) was not exactly a surprise:

“Patients have few sources from which to learn about illness and death. Acute illness – and, in particular, terminal illness – is for many people no longer part of everyday life. Therefore, images in the media strongly shape the public’s beliefs about medicine, illness, and death. The portrayal of CPR and death on three popular television programs is misleading in a number of ways.

[… T]hese three television programs give a misleading impression about the kind of people most commonly given CPR. On television, children, teenagers, and young adults accounted for 65 percent of the patients given CPR. Of the total number of deaths on the programs, 83 percent were of nonelderly patients. In fact, cardiac arrest is much more common in the elderly than in children or young adults … CPR succeeded more frequently on television than in the real world as reflected in the medical literature. On all three shows combined, 75 percent of the patients were alive immediately after their cardiac arrests, and 67 percent appeared to survive in the long term. On Rescue 911, which focuses on the successes of emergency services, the survival rate after CPR was 100 percent. Of the patients on ER, 65 percent survived the initial arrest; three of these patients died before discharge from the hospital. On Chicago Hope, 64 percent of the patients given CPR initially survived cardiac arrest, and 36 percent survived to discharge.

[…] Rates of long-term survival after cardiac arrest as reported in the medical literature vary from 2 percent to 30 percent for arrests outside a hospital, and from 6.5 percent to 15 percent for arrests that take place inside a hospital. For average elderly patients, the rate of long-term survival after cardiac arrest outside a hospital is probably no better than 5 percent. For arrests due to trauma, the reported survival rates vary from 0 to 30 percent. Clearly, the rates on television are significantly higher than even the most favorable data reported in the literature.”

What the authors worry even more about, besides the factual misrepresentations, is the effect that this phenomena has on patient expectations, espcially when patients and their families are making decisions about whether or not to attempt resuscitative events:

“In a subtle way, the misrepresentation of CPR on television shows undermines trust in data and fosters trust in miracles. In the stories retold on Rescue 911, physicians often predict poor outcomes for patients, while family members voice their hope and, in the end, their joy in the “miracle” of their loved ones’ recovery. We acknowledge that this drama produces good television, as evidenced by the large viewing audiences. However, these exceptional cases may encourage the public to disregard the advice of physicians and hope that such a miracle will occur for them as well. Faith is central to our ability to maintain hope in difficult situations and often is an important adjunct to the therapy physicians offer. Belief in miracles, however, can lead to decisions that harm patients. The portrayal of miracles as relatively common events can undermine trust in doctors and data.

Misrepresentations of CPR on television may lead patients to generalize their impressions to CPR in real life. For example, an 85-year-old woman with metastatic breast cancer may believe that CPR can work as well in her situation as it does for the 23-year-old trauma victim on television. Physicians discussing decisions about the end of life with patients and families should be aware that the public has many sources of information about CPR, some of them misleading. To help patients and families make informed decisions, doctors should encourage patients to discuss their impressions of CPR and its chances of success. We should clarify misperceptions, provide actual data on outcomes, and address specifically the differences between CPR as seen on television and CPR as it is experienced by real patients.”

The differences between medicine in real life compared to medicine as portrayed in television is clearly an important topic, and I hope that in the 10 years since this paper was published, that both television writers, patients and physicians have learned from the authors astute conclusions.

Equally problematic, however, is another phenomena in which television has raised unrealistic expectations of physicians. This phenomena was the subject of an important study recently published in the British Medical Journal:

Phenotypic differences between male physicians, surgeons, and film stars: comparative study
The problem is clear: physicians on television look nothing like physicians in real life. Not to say that there aren’t very aesthetically pleasing physicians and nurses. Believe me, there are. But for the most part, physicians look like people who’d rather leaf through the latest New England Journal of Medicine than the latest GQ or Esquire.

Except for the surgeons.

I remember first noticing, while a third year medical student, that the surgeons always seemed to dress a little sharper, walk a little taller, and have the nicest manicured hands. That’s not to say that the internists and pediatricians were all slobs. But you were more likely to see a rumpled looking, balding man with a tweed jacket heading to medicine grand rounds then to the operating room. And I’ve never seen a pediatric tie on a surgeon. Never. Not even a pediatric surgeon.

But I digress. Male physicians on television, for the large part, all tend to look, well, like television stars: tall, in-shape, square jaw, with a healthy glow. Think about it: Dr. Richard Kimball (The Fugative), Dr. Doug Ross (ER), that guy from Marcus Welby, a general practitioner, was a handsome devil. OK. Charles Emerson Winchester III wasn’t the most handsome figure on the small screen. But you get my point.

So here’s the problem: it appears that TV actors playing the parts of physicans look far better than the roles they play, raising unrealistic expectations of the true phenotype of physicians. Moreover, there appears to be a true phenotypic difference between the surgeons and internists. Could this possibly be true? The investigators write:

“The tallest and most handsome male [medical] students were more likely to go for surgery, and the shortest (and perhaps not so good looking) ones were more likely to become physicians (including doctors of internal medicine and its subspecialties). Now, after all these years we hypothesize that, on average, surgeons are taller and better looking than physicians. We conducted a comparative study to test this hypothesis.”

The authors of this cutting-edge research out of the University of Barcelona selected a random sampling of senior staff surgeons and internists, as well as external controls (Harrison Ford as Dr. Richard Kimble, George Clooney as Dr. Doug Ross, Patrick Dempsey as Dr. Derek Shepherd, and Hugh Laurie as Dr. Gregory House), and showed them to an independent group of eight female observers (3 doctors and 5 nurses). Each of the physicians, surgeons and control subjects were given a “good looking score”. The outliers were discarded and the six remaining scores were averaged (± standard deviations) and compared using a standard t test. or non-parametric (Mann-Whitney U) test.

The results: film stars (external controls) had significantly higher good looking scores than surgeons (5.96 versus 4.39, p=0.013) and physicians (5.96 versus 3.65, p=0.003). Surgeons had statistically significantly higher good looking scores than physicians (4.39 versus 3.65, p=0.010).

Moreover, the surgeons were taller (179.4 cm versus 176.2 cm, p=0.01), on average, than the internists. And to top it off the authors, “… noted a higher proportion of baldness (surrogate marker) among the internists.” Is there no justice for the humble internist!

Their discussion sheds remarkable insights into these findings:

“There are several potential explanations for the phenotypic changes between surgeons and physicians. Firstly, surgeons spend a lot of time in operating rooms, which are cleaner, cooler, and have a higher oxygen content than the average medical ward, where physicians spend most of their time. Furthermore, surgeons protect (but not always properly) their faces with surgical masks, a barrier to facial microtrauma, and perhaps an effective anti-ageing device (which deserves further testing). They often wear clog-type shoes, a confounding factor that adds 2-3 cm to their perceived height. The incidental finding that fewer surgeons are bald might be related to these environmental conditions and to the use of surgical caps.

In contrast, senior physicians are surrounded by fewer people in their habitat (the patient’s bedside and the office), and they therefore have less need to be easily identified or spotted by families and nurses in the middle of a swarm. Physicians tend to hang heavy stethoscopes around their necks, which bows their heads forward and reduces their perceived height. They also complain of a (clearly abnormal) need to endlessly update their knowledge in accordance with the current evidence based approach to medicine by reading and studying heaps of medical journals; this overload of information further grinds them down. Although a prospective study found that doctor’s white coats decrease in weight with increasing seniority, no significant difference was found between the mean weight of physicians’ coats and surgeons’ coats (1.4 v 1.5 kg).”

Well, it is clear that television still has a long way to go in accurately portraying medicine. I’ll be happy to continue using my TV as a place to pile my medical books and journals. Despite my techno-geek longings for a flat screen LCD, I have chosen to save the money for something more relevant (like a good bottle of wine, or a trip somewhere nice, or perhaps some eggs or cat litter). And while I grudgingly admit that the surgeons are a little taller, and the orthopaedic docs appear to be in better shape, I take solace in knowing that our jokes about them are much, much funnier than theirs about us.