Opinion
VIEWPOINT
Neal Baer, MD Global Media Center for Social Impact, Fielding School of Public Health, University of California, Los Angeles.
Corresponding Author: Neal Baer, MD, Global Media Center for Social Impact, Fielding School of Public Health, University of California– Los Angeles, Los Angeles, CA 90095 ([email protected]). jamainternalmedicine.com
The Circus Comes to the Emergency Department Television cameras have been in the emergency department (ED) ever since ABC News began airing a series of documentaries, such as Boston Med and NY Med, depicting the high-pitched life-and-death drama of saving lives in the ED. Renowned hospitals such as Johns Hopkins, New York–Presbyterian, Brigham and Women’s, Massachusetts General, and Boston Medical Center have welcomed camera crews into their EDs to present the wrenching decisions that physicians and their patients and families must make at the most critical times in their lives.1,2 That makes for great television. I know. I was a writer and producer on the hit television series ER for its first 7 seasons. We strove to tell emotional stories that we hoped would captivate the audience and, as an added bonus, educate them about disease processes and prevention. But at the end of a shooting day, it was still only make-believe. No one was really hit by a car or a bullet; no life-or-death decisions had to be made in an instant; and no one’s personal tragedy was hung out for all to see. But the stories on ABC News are not make-believe. They are real. And that is their selling point. But are they truly as “real” as the producers tout them to be? I am also a documentary filmmaker. I know that the times when I decide to turn on the camera, what I choose to edit in or out, and my very presence filming the subjects all affect the outcome of the film. I look for dramatic moments, and I have found that I encourage them in the questions I ask or in the people I choose to film. Those subjects need to be charismatic to hold the audience’s attention. So it is no surprise, then, that NY Med, a reality medical show produced by ABC, promotes one of the young trauma surgeons as “Dr McDreamy–like” as a nod to its dramatic series, Grey’s Anatomy. Therein lies the rub. Of course ABC would choose a Dr McDreamy–like surgeon from among all the surgeons at New York–Presbyterian, just as we cast George Clooney on ER to be a pediatrician the viewers would swoon over. It makes for good television. What else makes for good reality television? Dramatic moments. The executive producer of the ABC series echoed this view when he told Capital New York that his goal is to give the viewer “the ‘goodbye’ moment… where a family says goodbye to their loved one going into surgery[. I]f you don’t capture that moment, because a nurse shut the door on your camera’s face, you kill that piece.”3 The point here is that these reality medical series are much like the dramas that I wrote on ER. They are constructed—in their case from thousands of hours of footage, with telegenic physicians taking the viewer through the minefield of the decisions, elations, and tragedies only the ED can provide. I cannot say whether the pres-
ence of the camera crew had any impact on the decisions that these physicians made, but I do know that it does affect the participants’ behavior in terms of wanting to look competent and caring. We are human beings. We care about how we are being seen. And we may question our decisions, hesitate or refrain from being who we really are as physicians when the camera is recording our every move. This raises a broader question. Can filming be done in a manner that does not impinge on a physician’s duty to the patient? Reality television producers will argue affirmatively that as long as informed consent is in place everything is fine. But can a patient and family truly give consent when they are likely at their most vulnerable? Might they consent only because they do not want to alienate the physicians who are caring for them? Finally, does the benefit to the patient outweigh any possible harm that might come from filming? It is hard to see what benefit comes to a patient when his or her most personal problems are displayed on the television screen. Reality television producers also argue, and their sentiments are echoed by the chief executive officers of these hospitals, that these shows are educational and therefore that makes them above criticism. Indeed they are educational—no doubt viewers learn a great deal about critical care—but does that make them ethical? Even though the ABC News programs are produced under the news division, they must emotionally resonate with the audience. News shows, too, must deliver ratings; otherwise advertisers will withhold their dollars— which is why the producers look for those “goodbye moments,” which arguably may be in conflict with what is best for the patient. Am I saying, then, that reality television crews should never be allowed into the ED? Yes. The bottom line is that television journalists and physicians have different agendas. The agenda of television journalists is to tell compelling and dramatic stories; to find the most telegenic physicians; to capture all the messy conflict in the life-and-death decisions being made around the clock. Their agenda conflicts baldly with our duty to our patients. Despite what the executive producer of NY Med claimed, that “[i]n no way will your care be affected one way or another”4(p54) by the presence of camera crews, it cannot possibly be true because the goal of the television journalist is in direct conflict with the duty of the physician to the patient. The journalist needs the most compelling and dramatic moments and must get them in order to make the show successful. That has nothing to do with the physician caring for the patient. If the physician even moves ever so slightly to appease the reality television producer, then he or she is crossing the line, providing entertainment rather than compassionate care. As physicians, our job is to
(Reprinted) JAMA Internal Medicine June 2015 Volume 175, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a GAZI UNIVERSITESI User on 03/03/2016
883
Opinion Viewpoint
treat our patients in the best way we can, not to perform before cameras and not to allow our patients’ suffering to be fodder for a mass audience. If cameras do not belong in the ED, then is there a way to promote audience education that does not conflict with patient care? Physicians certainly have more venues now than in the past in which to discuss the complexities of caring for patients in the ED. In addition to books and magazines, there are blogs, Facebook, Twitter, and op-ed articles. We can inform the public about prevention and other aspects of medicine by going into classrooms, speaking before
groups and telling the stories that have moved us as physicians, while at the same time telling the stories in ways that fully protect the privacy of patients and their families. And we must take evidencebased research and tell stories that accurately reflect the findings of such research to combat the rampant misinformation that is too often posted on the Internet. By sharing our stories publicly or through social media, we can connect with audiences in ways that were never possible before. We do not have to tell our stories by allowing reality television crews to hunt for and intrude on the most sacred moments between a patient and physician.
ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamainternmed.2015.1112.
1. Baer N. First, do no harm. J Clin Ethics. 2013;24 (1):64-66.
Conflict of Interest Disclosures: Dr Baer is cofounder of the Global Media Center for Social Impact at the Fielding School of Public Health at the University of California, Los Angeles, and is executive producer of Under the Dome, CBS Television. No other disclosures are reported.
2. Ornstein C. When a patient’s death is broadcast without permission. ProPublica. January 2, 2015. http://www.propublica.org/article/when-a-patients -death-is-broadcast-without-permission. Accessed February 25, 2015.
3. The 60-Second interview: Terence Wrong, executive producer of “NY Med” on ABC. Capital New York. June 26, 2014. http://www.capitalnewyork .com/article/media/2014/06/8548028/60-second -interview-terence-wrong-executive-producer-ny -med-abc. Accessed February 25, 2015. 4. Krakower TM, Montello M, Mitchell C, Truog RD. The ethics of reality medical television. J Clin Ethics. 2013;24(1):50-57.
LESS IS MORE VIEWPOINT
Udayan K. Shah, MD University of Texas Southwestern Medical Center, Dallas. Carol DiMura, MSN BayCare Health System, Clearwater, Florida. Deepak Agrawal, MD University of Texas Southwestern Medical Center, Dallas.
Corresponding Author: Deepak Agrawal, MD, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, PO Box 1, 5-520, Dallas, TX 75390 (deepak.agrawal @utsouthwestern.edu). 884
When Documentation Supersedes Patient Communication An Example From an Endoscopy Unit A patient who underwent screening colonoscopy at our hospital made an astute observation: many of the questions that he was asked in a preprocedure assessment seemed out of place and irrelevant. Among the questions were, “Do you want to know more about your health condition?” and “Are you interested in ways to keep you healthy?” The patient asked us what we did with his answers. The truth was that the answers did not alter his care in any way. Agreeing with the patient’s sentiments, we investigated the rationale behind the questions in the preprocedure learning assessment (Table). We attended local and regional Society of Gastroenterology Nurses and Associates conferences in 2014 and surveyed nurses representing endoscopy units throughout Texas. Of 210 nurses surveyed, 70% reported routinely asking questions similar to those in the Table. Most believed that the questions were regulatory requirements but did not know who mandated them or wrote them. More importantly, the nurses who asked these questions did not believe that they had an effect on patient care. There were several reasons. First, patients require minimal teaching for routine outpatient procedures, which is largely covered when informed consent is obtained. Second, most health systems are not designed to react to the answers. For example, patients who cannot read are still given written (along with verbal) discharge instructions. Simi-
Table. Preprocedure Learning Assessment for Screening Colonoscopy Question
Answer Options
Highest grade level completed
0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12 No college, some college, graduate, technical, other
Can you read?
Literate, illiterate English, Spanish, other languages
Can you write?
No, English, Spanish, other
What is the best way for you to learn new things?
Reading, talking about them, pictures, hands-on demonstration, listening, video
What problems may get in the way of your learning?
None, seeing, hearing, glasses, contacts, hearing aid, deaf, physical problem, emotions, mental, other
Do you have any cultural or spiritual beliefs that may affect your ability to learn or understand the information provided?
Yes, no, maybe, not sure
Are you interested in learning about your health problems?
Yes, no, maybe, not sure
Are you interested in how your health problems can be treated?
Yes, no, maybe, not sure
Are you interested in ways to keep you healthy?
Yes, no, maybe, not sure
larly, if a patient states that he or she is not interested “in learning about your health problems,” nurses still try to help the patient understand the procedure and the
JAMA Internal Medicine June 2015 Volume 175, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a GAZI UNIVERSITESI User on 03/03/2016
jamainternalmedicine.com
VIEWPOINT
Neal Baer, MD Global Media Center for Social Impact, Fielding School of Public Health, University of California, Los Angeles.
Corresponding Author: Neal Baer, MD, Global Media Center for Social Impact, Fielding School of Public Health, University of California– Los Angeles, Los Angeles, CA 90095 ([email protected]). jamainternalmedicine.com
The Circus Comes to the Emergency Department Television cameras have been in the emergency department (ED) ever since ABC News began airing a series of documentaries, such as Boston Med and NY Med, depicting the high-pitched life-and-death drama of saving lives in the ED. Renowned hospitals such as Johns Hopkins, New York–Presbyterian, Brigham and Women’s, Massachusetts General, and Boston Medical Center have welcomed camera crews into their EDs to present the wrenching decisions that physicians and their patients and families must make at the most critical times in their lives.1,2 That makes for great television. I know. I was a writer and producer on the hit television series ER for its first 7 seasons. We strove to tell emotional stories that we hoped would captivate the audience and, as an added bonus, educate them about disease processes and prevention. But at the end of a shooting day, it was still only make-believe. No one was really hit by a car or a bullet; no life-or-death decisions had to be made in an instant; and no one’s personal tragedy was hung out for all to see. But the stories on ABC News are not make-believe. They are real. And that is their selling point. But are they truly as “real” as the producers tout them to be? I am also a documentary filmmaker. I know that the times when I decide to turn on the camera, what I choose to edit in or out, and my very presence filming the subjects all affect the outcome of the film. I look for dramatic moments, and I have found that I encourage them in the questions I ask or in the people I choose to film. Those subjects need to be charismatic to hold the audience’s attention. So it is no surprise, then, that NY Med, a reality medical show produced by ABC, promotes one of the young trauma surgeons as “Dr McDreamy–like” as a nod to its dramatic series, Grey’s Anatomy. Therein lies the rub. Of course ABC would choose a Dr McDreamy–like surgeon from among all the surgeons at New York–Presbyterian, just as we cast George Clooney on ER to be a pediatrician the viewers would swoon over. It makes for good television. What else makes for good reality television? Dramatic moments. The executive producer of the ABC series echoed this view when he told Capital New York that his goal is to give the viewer “the ‘goodbye’ moment… where a family says goodbye to their loved one going into surgery[. I]f you don’t capture that moment, because a nurse shut the door on your camera’s face, you kill that piece.”3 The point here is that these reality medical series are much like the dramas that I wrote on ER. They are constructed—in their case from thousands of hours of footage, with telegenic physicians taking the viewer through the minefield of the decisions, elations, and tragedies only the ED can provide. I cannot say whether the pres-
ence of the camera crew had any impact on the decisions that these physicians made, but I do know that it does affect the participants’ behavior in terms of wanting to look competent and caring. We are human beings. We care about how we are being seen. And we may question our decisions, hesitate or refrain from being who we really are as physicians when the camera is recording our every move. This raises a broader question. Can filming be done in a manner that does not impinge on a physician’s duty to the patient? Reality television producers will argue affirmatively that as long as informed consent is in place everything is fine. But can a patient and family truly give consent when they are likely at their most vulnerable? Might they consent only because they do not want to alienate the physicians who are caring for them? Finally, does the benefit to the patient outweigh any possible harm that might come from filming? It is hard to see what benefit comes to a patient when his or her most personal problems are displayed on the television screen. Reality television producers also argue, and their sentiments are echoed by the chief executive officers of these hospitals, that these shows are educational and therefore that makes them above criticism. Indeed they are educational—no doubt viewers learn a great deal about critical care—but does that make them ethical? Even though the ABC News programs are produced under the news division, they must emotionally resonate with the audience. News shows, too, must deliver ratings; otherwise advertisers will withhold their dollars— which is why the producers look for those “goodbye moments,” which arguably may be in conflict with what is best for the patient. Am I saying, then, that reality television crews should never be allowed into the ED? Yes. The bottom line is that television journalists and physicians have different agendas. The agenda of television journalists is to tell compelling and dramatic stories; to find the most telegenic physicians; to capture all the messy conflict in the life-and-death decisions being made around the clock. Their agenda conflicts baldly with our duty to our patients. Despite what the executive producer of NY Med claimed, that “[i]n no way will your care be affected one way or another”4(p54) by the presence of camera crews, it cannot possibly be true because the goal of the television journalist is in direct conflict with the duty of the physician to the patient. The journalist needs the most compelling and dramatic moments and must get them in order to make the show successful. That has nothing to do with the physician caring for the patient. If the physician even moves ever so slightly to appease the reality television producer, then he or she is crossing the line, providing entertainment rather than compassionate care. As physicians, our job is to
(Reprinted) JAMA Internal Medicine June 2015 Volume 175, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a GAZI UNIVERSITESI User on 03/03/2016
883
Opinion Viewpoint
treat our patients in the best way we can, not to perform before cameras and not to allow our patients’ suffering to be fodder for a mass audience. If cameras do not belong in the ED, then is there a way to promote audience education that does not conflict with patient care? Physicians certainly have more venues now than in the past in which to discuss the complexities of caring for patients in the ED. In addition to books and magazines, there are blogs, Facebook, Twitter, and op-ed articles. We can inform the public about prevention and other aspects of medicine by going into classrooms, speaking before
groups and telling the stories that have moved us as physicians, while at the same time telling the stories in ways that fully protect the privacy of patients and their families. And we must take evidencebased research and tell stories that accurately reflect the findings of such research to combat the rampant misinformation that is too often posted on the Internet. By sharing our stories publicly or through social media, we can connect with audiences in ways that were never possible before. We do not have to tell our stories by allowing reality television crews to hunt for and intrude on the most sacred moments between a patient and physician.
ARTICLE INFORMATION
REFERENCES
Published Online: April 20, 2015. doi:10.1001/jamainternmed.2015.1112.
1. Baer N. First, do no harm. J Clin Ethics. 2013;24 (1):64-66.
Conflict of Interest Disclosures: Dr Baer is cofounder of the Global Media Center for Social Impact at the Fielding School of Public Health at the University of California, Los Angeles, and is executive producer of Under the Dome, CBS Television. No other disclosures are reported.
2. Ornstein C. When a patient’s death is broadcast without permission. ProPublica. January 2, 2015. http://www.propublica.org/article/when-a-patients -death-is-broadcast-without-permission. Accessed February 25, 2015.
3. The 60-Second interview: Terence Wrong, executive producer of “NY Med” on ABC. Capital New York. June 26, 2014. http://www.capitalnewyork .com/article/media/2014/06/8548028/60-second -interview-terence-wrong-executive-producer-ny -med-abc. Accessed February 25, 2015. 4. Krakower TM, Montello M, Mitchell C, Truog RD. The ethics of reality medical television. J Clin Ethics. 2013;24(1):50-57.
LESS IS MORE VIEWPOINT
Udayan K. Shah, MD University of Texas Southwestern Medical Center, Dallas. Carol DiMura, MSN BayCare Health System, Clearwater, Florida. Deepak Agrawal, MD University of Texas Southwestern Medical Center, Dallas.
Corresponding Author: Deepak Agrawal, MD, University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, PO Box 1, 5-520, Dallas, TX 75390 (deepak.agrawal @utsouthwestern.edu). 884
When Documentation Supersedes Patient Communication An Example From an Endoscopy Unit A patient who underwent screening colonoscopy at our hospital made an astute observation: many of the questions that he was asked in a preprocedure assessment seemed out of place and irrelevant. Among the questions were, “Do you want to know more about your health condition?” and “Are you interested in ways to keep you healthy?” The patient asked us what we did with his answers. The truth was that the answers did not alter his care in any way. Agreeing with the patient’s sentiments, we investigated the rationale behind the questions in the preprocedure learning assessment (Table). We attended local and regional Society of Gastroenterology Nurses and Associates conferences in 2014 and surveyed nurses representing endoscopy units throughout Texas. Of 210 nurses surveyed, 70% reported routinely asking questions similar to those in the Table. Most believed that the questions were regulatory requirements but did not know who mandated them or wrote them. More importantly, the nurses who asked these questions did not believe that they had an effect on patient care. There were several reasons. First, patients require minimal teaching for routine outpatient procedures, which is largely covered when informed consent is obtained. Second, most health systems are not designed to react to the answers. For example, patients who cannot read are still given written (along with verbal) discharge instructions. Simi-
Table. Preprocedure Learning Assessment for Screening Colonoscopy Question
Answer Options
Highest grade level completed
0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12 No college, some college, graduate, technical, other
Can you read?
Literate, illiterate English, Spanish, other languages
Can you write?
No, English, Spanish, other
What is the best way for you to learn new things?
Reading, talking about them, pictures, hands-on demonstration, listening, video
What problems may get in the way of your learning?
None, seeing, hearing, glasses, contacts, hearing aid, deaf, physical problem, emotions, mental, other
Do you have any cultural or spiritual beliefs that may affect your ability to learn or understand the information provided?
Yes, no, maybe, not sure
Are you interested in learning about your health problems?
Yes, no, maybe, not sure
Are you interested in how your health problems can be treated?
Yes, no, maybe, not sure
Are you interested in ways to keep you healthy?
Yes, no, maybe, not sure
larly, if a patient states that he or she is not interested “in learning about your health problems,” nurses still try to help the patient understand the procedure and the
JAMA Internal Medicine June 2015 Volume 175, Number 6 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a GAZI UNIVERSITESI User on 03/03/2016
jamainternalmedicine.com
