From A Prescription for Realism
Just outside the high-pressure ER of fictional Seattle Grace Hospital, home of hit ABC show Grey's Anatomy, Dr. George O'Malley is about to make a stupid but believable mistake. As the doctor -- played by T. R. Knight -- sticks a needle in his patient's arm to draw blood, a drop falls unnoticed onto a piece of gauze. Instead of containing the waste, the doctor hands it, along with the blood sample, to a nurse, who passes it along to a lab tech. Suddenly, chaos erupts as everyone exposed becomes woozy and collapses.The episode being filmed comes from a real-life case in Southern California: A woman undergoing chemotherapy ingests some kind of herbal remedy, and the combination emits toxic fumes from her body, causing her attending doctors to pass out. But it wasn't enough for the producers of Grey's Anatomy to have their latest story line based on reality; they wanted to make sure all the medical details on the set added up. To do that, they called in Linda Klein, who, after working for more than ten years as a surgical tech and nurse, recently became a producer and medical consultant for Grey's Anatomy and Nip/Tuck, the popular FX series about two racy Miami cosmetic surgeons.
To show the actors how to realistically perform their doctorly duties, to make sure the props -- from blood syringes to suture-removal kits -- are authentic, and to keep scriptwriters' scenarios from veering into fantasy, Klein puts in long hours on Anatomy's set whenever medical procedures are being filmed.
"Linda takes the time to show us exactly how something should be done," says Ellen Pompeo, who plays Anatomy's title character, Dr. Meredith Grey (and, as fans will know, the love interest of Dr. Derek "McDreamy" Shepherd). "She makes sure everything is done perfectly."
As medical dramas have evolved from fiction to near fact, professionals like Klein have become the backbone of such hit shows as House and ER. They teach actors how to hold a scalpel, insert (fake) intubation tubes, perform CPR, choreograph operations, make incisions into lifelike (prosthetic) chests and brains, and speak and think like doctors -- all with the goal of giving TV viewers the prescription they've come to crave: a heavy dose of realism.
For decades, Americans have had a love affair with medical dramas, popularized in the early 1960s with the hit TV shows Dr. Kildare and Ben Casey. Back then, the parameters of medical depiction were limited. The central characters were handsome, flawless, godlike figures who rarely got blood on their hands and never made mistakes. The sanitized image of medicine and its practitioners was a reflection of the script-approval process: Until the mid-1970s, producers routinely submitted scripts to the American Medical Association for review.
By the early '70s, Marcus Welby, M.D. and Medical Center began dealing with controversial social issues -- rape, homosexuality, sexually transmitted diseases -- yet still clung to an idealized view of doctors and hospitals. In response to the profound social and political changes sparked by the Vietnam era came M*A*S*H, about an Army corps of wisecracking doctors during the Korean War. Against a backdrop of dramatic emergency surgeries performed in wartime, the medics were portrayed as heroes with flaws: libidinous, nurse-chasing boozers with hearts of gold.
"The only way the show could get away with those characters is that as surgeons, they had to be technically beyond reproach and behave correctly as doctors," says Joseph Turow, professor of communication at the Annenberg School of Communication, University of Pennsylvania.
Ironically, it was a show written by a novelist that ultimately broke through in terms of medical reality. Created in 1994 by Michael Crichton, ER launched the career of George Clooney, who played the charming, flirtatious Dr. Doug Ross. "We wanted to show what it was really like to be a doctor in an emergency setting: their flaws and exhaustion, the crowded waiting room, the explicit surgeries, successful and botched," says Dr. Fred Einesman, ER's medical advisor. "The show became a phenomenon in the medical community at the time because it was so accurate."
Einesman would know. He worked for more than 15 years as an ER doctor at Cedars-Sinai Medical Center in Los Angeles. "In the beginning," he recalls, "we said 'That's too bloody to show,' or 'We can't use technical medical jargon.' But now, viewers expect it to be real."
"In Hollywood, what sells is sex and violence," says Professor Turow. So when ER has to get people's attention in sweeps week, it has an incredible helicopter crash or a bus accident with lots of blood. Or Grey's Anatomy has two people impaled on a pole.
Today, there are few taboo subjects. AIDS, abortion, even the death penalty have been addressed on recent episodes of House. When a death row inmate becomes seriously ill, Dr. Gregory House, the chronically cranky, pain-pill-addicted medical genius played by Golden Globe winner Hugh Laurie, rises to the diagnostic challenge. Is it a tumor, a blood disease? No, turns out the inmate ingested toxic copy machine fluid, wanting to have control over his own death.
The Scary Truth
Infusing medical authenticity starts with finding real cases. Stories come from everywhere. Magazines, newspapers, medical journals -- including JAMA and Annals of Emergency Medicine -- and nurses and residents around the country. "I'm always asking people I meet at parties if they know of interesting cases, and they usually do," says Tony Phelan, an executive producer on Grey's Anatomy.ER's medical advisor Einesman has seen several of his real-life cases end up as episodes, and he recalls one that still haunts him to this day.
In the mid-1980s, a 45-year-old man was rushed to the hospital after having a massive heart attack. "When we did CPR, he would open his eyes," Einesman recalls, "but every time we stopped, his eyes would close and he'd fade away. This went on for 40 minutes, until finally we had to let him go. When I saw it on ER, I became emotional for the first time; in the hospital I had to remain objective and didn't have the luxury of reacting emotionally."
Einesman has shared that lesson in reality when advising actors about how to make their interactions with patients look real. "I tell them, 'You don't have time to emote here; you have to get the job done. There are 35 people in the waiting room, and you have to see one patient every 15 minutes.' "
On House, consultant David Foster, formerly an instructor at Harvard Medical School, makes sure the title character sounds authentic while talking about medical jargon. "When House and his team argue about a particular diagnosis," says Foster, "it has to be a condition that is actually debatable." Character is one thing, but the props and special effects are equally important. Chest cavities, ribs, layers of intestines, hearts and brains -- usually prosthetics made of latex and rubber -- have to be anatomically correct. Medical consultant Linda Klein sometimes relies on her local butcher shop to supply cows' brains and intestines.
Scrupulous attention is also paid to getting the various consistencies of blood right. According to ER's Einesman, there are 17 different types, including circulating, congealed and mouth blood -- appropriate for specific procedures or injuries. Karo syrup mixed with blue and red dye, for example, gives the thick, drying blood you'd see congealed on an old knife wound or a battered corpse.
Actual cervical-spine x-rays and MRIs from anonymous patients' files are used on ER, and the medical equipment on these shows -- heart monitors, respirators, EKGs -- is also authentic, as are the machines' numerical readings to reflect the cases being portrayed.
Still, for all their realism, these dramas remain, at heart, fiction. "They set up unrealistic expectations about doctors and hospitals," points out Professor Turow. "Who wouldn't want a Dr. McDreamy listening intently to their problems? But when you go to a hospital, it can be a scary place. Doctors and nurses are overloaded, and in these days of managed care, you're lucky if you see the same doctor twice."
"The idea that there's one brilliant doctor, like Gregory House, who would become that invested in a real-life patient's case is very appealing," says David Foster. "Anyone who's gone to an HMO knows differently."
A persistent criticism of these series from the medical community is the survival rate of both CPR and coma patients, which medical research says is much less successful in real life. Another criticism: Nobody ever talks about money or insurance.
"Now and then on ER, you'll get the sense of a beleaguered hospital with people waiting for care," Turow says. "But you don't see anyone at the reception booth being asked for their insurance card. And there's no real social context -- American society owning up to what it means to have the baby-boom generation marching toward its final years."
Still, there's no arguing with one aspect of medical dramas. The successful formula of presenting doctors who care but have flaws and make mistakes leads to a scary truth. Says Turow, "It's a crapshoot on these shows as to whether a patient will come out okay -- which is just like in the real world."