It's Only Television

Why should we care how medicine is depicted on TV? Aside from personal pique at the video caricatures of your profession, isn't it all a bit like obsessing over whether Star Trek warp drive is really possible?

Not if the actors who play doctors on TV affect what real viewers believe-and do-about their own health and medical decisions; and indeed, it appears that the membrane separating reality from fiction in the minds of TV viewers is leaky.

In my last column (2/25/07 issue), I wrote about an episode of ER that played a role in the successful lobbying effort to boost federal funding of patient navigator programs. Harold Freeman, MD, who pioneered patient navigators at Harlem Hospital, brought the concept to the attention of ER writers. He told them that patient navigators were effective at working with some cancer patients who didn't relate well to health care professionals. As an example, he told the writers about patients who had resisted the treatment advice of oncologists because they believed that cancer surgery actually causes cancer to spread.

Dr. Freeman, President and Medical Director of the Ralph Lauren Center for Cancer Care and Prevention and Senior Advisor to the NCI Director, and a member of OT's Editorial Board, applauded the ER storyline that incorporated both the challenge of cancer myths and the solution of patient navigators.

I think they made the point very clearly that there are people who delay essential treatment because of mythological beliefs, and that was a very educational episode, he said. I think they have a powerful tool.

Michael Miller, an NCI press officer, regularly works with TV writers and producers. He sees special value in dramatic portrayals of health and medical concepts, such as the ER storyline on patient navigators.

You see it dramatized. You see this woman coming into the ER and then how they find a patient navigator to work with her, after failing with some other methods that are fairly typical in a hospital. I think the folks involved with the program got a better understanding of ways in which to try to communicate what their program is about to the public, Miller says.

Vicky Rideout, at the Kaiser Family Foundation, echoes these endorsements of the influence of entertainment television.

Television consumes so much of people's time, and so many of the shows are either directly on health or reality shows on health or are modeling behaviors that impact health, that it is a hugely important medium, Rideout says.

She isn't expressing just her beliefs or personal observations. She's got data, including national surveys of 3,500 regular viewers of ER that were done before and after shows that contained specific medical information. One show included a brief subplot about a woman seeking emergency contraception and the other briefly mentioned that a patient's cervical cancer might be linked to sexual transmission of human papillomavirus (HPV).

In both surveys, awareness jumped a week after the episodes aired, although it subsided over time.

As far as the overall influence of the show, the researchers reported that about a third of viewers said that they had gotten information from the series that helped them make choices about health care; and about one in seven contacted a health care professional because of something that was on ER.

Both the emergency contraception and HPV storylines got very similar results. I would love to do it with another show and get further reinforcement, but it just increases my confidence in the findings that it happens with two different storylines, Rideout says. She says the effect of a one-minute discussion of the link between HPV and cancer was remarkable:

That's a pretty powerful one. It's more than people just telling you in general that they learned something. They actually can tell you what HPV is, when they couldn't the week before.

Hollywood, Health & Society Program at USC Monitors Effects of TV

The effects of entertainment television are monitored also by the Hollywood, Health & Society (HH&S) program at USC Annenberg's Norman Lear Center in Los Angeles, in part to justify the funding the program gets from the NCI, CDC, the Agency for Healthcare Research & Quality, and other agencies.

What would be the value of that television program if you bought it yourself, or if you tried to purchase a PSA [public service ad] or an ad? is one question that the NCI's Michael Miller asks when he evaluates their Hollywood outreach efforts. For the $350,000 [NCI] investment, the return is in the tens of millions of dollars, he said. You can look at the Nielsen [ratings] numbers and see the millions of people you reach, the hundreds of millions of people.

As I've described in earlier columns, the HH&S program connects TV writers and producers with health and medical experts who can answer technical questions, and it also reaches out to shows with story ideas that might provide both dramatic and public health value.

Last season, after HH&S briefings, both ER and Grey's Anatomy did episodes in which characters faced BRCA gene testing and its implications. Surveys before and after the episodes aired indicate that viewers who saw both shows knew more than non-viewers about the BRCA gene and the option of prophylactic mastectomy.

These viewers were also more likely to take action by scheduling a breast exam. The researchers concluded that ER produced a stronger effect, perhaps because of its format, which focuses more on medicine, compared with the soap opera overtones of Grey's Anatomy.

After the Spanish-language soap opera, or telenovela, Ladrón de Corazones aired a breast cancer storyline, a survey demonstrated that viewers learned about diagnosis and treatment and were more likely than non-viewers to talk to other people about cancer and to call for cancer information.

In 2001, a CDC hotline for HIV/AIDS information recorded its biggest spike in calls during that year, more than 5,300 call attempts, after a character on the soap opera The Bold & The Beautiful displayed the hotline number as part of an AIDS storyline. The researchers wrote that the hotline now tries to prepare for surges whenever HIV and AIDS come up in popular TV shows.

Many Questions Remain about the Ultimate Impact on Health Beliefs & Behaviors

However, even though most studies of entertainment education indicate that TV dramas are influential, many questions remain about the ultimate impact on health beliefs and behaviors.

I don't think we really know how people interpret a lot of the content, says Vicky Rideout.

Entertainment television seems to be particularly suited to addressing disparities in health knowledge and behavior. While many health education efforts have trouble connecting with those who need the information the most, entertainment TV appears to have a bigger effect in populations at higher risk. It makes sense when you think about it; heavy TV viewing is associated with both higher risks of ill health and with other risk factors, so infusing TV programs with health messages will preferentially reach higher-risk populations.

And although it pains this veteran TV news reporter to admit it, entertainment shows have an edge over news and documentaries.

They are particularly good at translating a complex issue in a way that it can be understood by people. They tell stories; so they can illustrate how that issue is actually relevant to somebody's life. And the characters that they use, and the stories that they tell, can engage the public and make them care, Rideout says.

And entertainment programs have much larger audiences.

The Kaiser Family Foundation survey asked the ER viewers where they first heard about HPV. The show was mentioned more than twice as often as doctors or other health care providers. Other TV shows, newspapers, and magazines trailed even further behind.