Whether or not patients’ perceptions of health care should be shaped by portrayals in entertainment, there’s no escaping the fact that this fictional content is indeed impactful.
In the first of two “AMA Moving Medicine” podcast episodes about pop culture’s impact on the way patients view and understand health care, the AMA Medical Student Section’s Committee on Bioethics and Humanities is joined by Michael Metzner, MD, medical communications fellow on the set of Grey’s Anatomy, and Jeanne M. Farnan MD, MHPE.
Moderator: Our first question is for Dr. Metzner. How do you balance giving a factual account of a medical topic while working within their allotted time limit and fitting it within a dramatic narrative? How do you approach what content to include in terms of the medical depth with the time that you're given?
Dr. Metzner: I get this question a lot. I have one of the best jobs in the world because, unlike treating one patient and impacting one person at a time, I get to help create stories that tens of millions of people watch every week. You can actually have a pretty large impact. It's kind of a dangerous thing, too, because if you show things on television that aren't as accurate, the problem is that you're misinforming a pretty large population, and they come to their doctor and they're like, "Well, I saw it on Grey's Anatomy."
This is actually a really important question and something that our team at Grey's cares a lot about. You can watch a lot of television shows, and being health care providers or with a medical school, a lot of times you're like, "That's never going to happen," but you'd be surprised.
Actually, we have a team of physicians who work on Grey's Anatomy, me being one. We have four full-time doctors, four consultants in all different specialties, and then we actually work with experts around the world.
Although you might say, "Oh, that's never going to happen," almost 99.9% are actually based off of case reports where, yes, it is that one in a million. Yes, it's probably the one in a million in the one in a million, but a lot of times it actually has happened, which a lot of people are surprised when they hear that.
Anytime I'm asked this question, it comes down to the balance between drama and reality in medicine. We have all these people who watch the show, and if we were to follow the real protocols of what we do—let's say, if we were looking at the immunofluorescence of a biopsy sample, which takes eight hours in order to produce a result—we wouldn't have a million people watching the show, right? So, we have to make it very dramatic and engaging, but we also try and create it rooted within science.
That's something that we're always working on. Yes, we do time jumps of what would be in reality. Someone who is extubated minutes after they just had an open-heart surgery. Sometimes it can happen, but on our show it always happens because they have to speak. It is a fine balance.
The way that we come up with the stories, actually, we'll either have writers who have read something on Buzzfeed or in The New York Times, and then we'll delve in to see what the validity of that is. Or for the stories, we have our own experiences. A couple of the stories this past season were actually based on patients that I had in San Antonio. Again, it's a balance, and it's a very hard teeter-tottering thing to do, but we do our best.
Moderator: Nice. Thanks. This next question is for Dr. Farnan. How can we use social media as a platform to connect to a wider nonmedically oriented audience while still maintaining accuracy and professionalism?
Dr. Farnan: When I started doing this work circa 2008, my interest in the area actually started because of a video that our medical students, then rising M2s, had produced and posted on YouTube to the shock and awe of many faculty at the university, including the alumni association, which required a lot of response.
Now just in nine years, 10 years, the evolution of the presence of medical students on social media has really exploded and changed a lot. I think that the initial policy statements and positions of medical schools was very much one of a punitive approach and keeping students aware of what their presence should be. I think now we're really evolving into thinking about how do we really encourage students to become not only physicians and scholars and educators, but also advocates. Social media has been, I think, an incredibly powerful tool for advocacy.
In terms of your question ... I think first and foremost is to take a step back and think about what you're putting out there yourself and how you are doing it. I will say that one thing that's different about being a physician, and I know you all are at various levels of training, is that we don't get to take it off when we leave.
There are only two professions where you theoretically "change your name," right? It's the priesthood or the clergy and being a physician. You are Dr. So-and-So in the hospital and Dr. So-and-So outside of the hospital, and it very much impacts the representation and how people interpret our messages.
I do think that you should think about what you're posting and in what role you are posting it in. Are you posting it as a medical student or are you posting it as an individual who happens to feel one way or another about a certain social or political issue? You have to be very thoughtful about that. I think it is much more expected now that students do engage and that it becomes less of this concern that residency programs are screening social media to see who's posting inappropriate things on Facebook.
Nobody's on Facebook anymore, but the idea that the things that you're putting out there may negatively impact you, I think that ship has sailed and we're really thinking about how do we use social media as a tool to unite students and to really unite folks across the world around really important issues. With #WomenInMedicine and #ILookLikeASurgeon, there are lots of really important initiatives that have developed that have been grassroots for students.
Accuracy is an issue. Make sure that you're posting evidence-based information and being very thoughtful about providing medical advice. ... It's complicated, but I encourage students to maintain a voice. Because I think that in the absence of a voice—whether it's the AMA as a large organization, individual faculty, or students—without a voice from the physician community, we leave a void that is filled with misinformation. I think encouraging students to embrace that position and be out there and proactive is important.
Moderator: This next question is actually for both of you. How do you approach trying to cover a more ethically sensitive topic? Maybe something along the lines of physician-assisted suicide or abortion or any kind of ethically sensitive topic?
Dr. Metzner: How many of you have watched Grey's Anatomy? We probably all have watched it at some point in our life. Anyone still watch Grey's Anatomy? This season I think we did one of the most amazing jobs on a really sensitive topic, and if you haven't watched this episode, I'm pushing the show on you right now, but you have to go watch it. It's called “Silent All These Years,” and it follows this woman who was sexually abused. Her husband was out of town, she was out drinking with her friend, she was walking home, and then she was raped in an alley.
When we talk about these kind of sensitive issues—and, of course, with Grey's, we try and push the limit as much as we can, but this was a really important story—we do so much research. We spoke to so many survivors. We engaged so many organizations that focus on what the needs are for these kinds of survivors, and we created a story that to this day, I don't know how we're ever going to beat it. It was the most remarkable piece of television entertainment topic that I've ever had.
I was so happy and humble to be part of this team to create that story. ... The day after, the RAINN Association, which is the Rape, Abuse & Incest National Network, their calls actually increased by 43% after we showed that. We've just had so much outreach from women and men who have been victims.
When we talk about these kinds of topics, it's not just, "Oh, we're going to write a really compelling story." We do so much research to make sure that what we're conveying is important. We actually did a public service announcement, PSA kind of thing, as a trigger warning even before we put this on prime-time television, because we showed every step of what actually goes into a rape kit.
It's the first time in TV history that we went through each of those steps. Watching it, I've probably seen it about eight times now, and every time I'm choked up. But the power of that, and empowering those survivors, it's just amazing that we have that modality to reach so many people.
Moderator: Thanks. Same question for you, Dr. Farnan.
Dr. Farnan: It's just a little bit more complicated, I think, for the individual student. Ethically charged and sensitive issues come up constantly, and I think that we're all very aware of the current conversations about reproductive health rights and a lot of other conversations. ...
I think that for an individual student it's a little bit more difficult when you try to navigate these waters, because they really are issues of representation, and there are actually legal precedents about what an individual student can do in their role as a student of X institution. How many of your schools allow you to protest with your white coats that are branded? I see some heads shaking no. Some schools allow students to protest with their branded medical school white coats.
How many students are at schools where your administration has told you that you are not allowed to wear branded materials, to do protests or any other kind of political action? There's several of you. A lot of that has to do with state-based schools versus private schools and federal funding versus not. Students at private institutions have a little bit more leeway because they're not as bound to federal tax dollars. ...
I'm sure you know, if you follow anybody who's present, who's very active on Twitter or any other social media platform, you'll often see “tweets are my own and do not represent the views of my employer.” I think every single person sort of has that in their byline so that individuals are aware of that these are my personal political viewpoints.
I think also, if you are kind of wading into that water of social media, what do you want to put out there? Do you want to put everything out there? Some people keep their personal and their professional identities very separate. Maybe I don't want everybody following me to see my son, his graduation, or how I feel about baseball because in Chicago that's very polarizing. Go White Sox.
You have to make those decisions, I think, before you are deciding to get into that water. But once you do decide, then I think that being true to what you believe is incredibly important. Really having authentic participation in whatever thing it is that you are passionate about. I think this is really going to be what moves us forward as a community of physicians. I mean, there are a lot of things right now that are in the ether of social media that people are discussing and people are not afraid to share their views about.
I think that I would encourage all of you to, once you know what your policy-based limitations are at your individual schools, is to advocate as strongly as you want for things that you believe in because I think that that is really important. Because we should advocate for, not only ourselves and our personal views, but advocate for our patients, which is the most important thing.
Moderator: This is another question for both of you pertaining to how media and big media, such as Grey's Anatomy and even our personal social media, can affect public perceptions or patient attitudes. How do you view the impact of media? I'm thinking in terms of chronic illness or terminal illness or things where there's generally an approach that we need to be fighters and we need to go forward and give it all we got.
A specific example I'm thinking of is Alex Trebek recently was diagnosed with stage IV pancreatic cancer. People with his condition, about 9% have a good outcome and aren't killed by it immediately. His immediate reaction was, “I'm going to fight it.” He thankfully managed to. I think he's in remission right now if my news is correct. But for something like this, we have so much emphasis on being a fighter. Do we overdo that? What are your thoughts?
Dr. Metzner: Well, you know on Grey's, we're storytellers. I have examples where I could give you for both. We have that patient who, no matter what, they're going to fight for their life and whether or not they make it or not depends on that story. But there was another patient this season where she actually fell off a balcony. She was a day before her wedding. She ended up having her wedding in the ICU as they were taking her off life support. Yeah, I know, very dramatic. But trust me, you watch that and you try to keep a dry eye.
But to your question, I think it is important to show that story on both sides of the coin. I think as a society, I'm sure we'd all agree. A lot of people believe that one of the biggest problems within health care right now is that most of the costs are in that last six months of life. We have the mentality that we have to fight no matter what. We have to do every measure that we can.
Being a general surgery resident, I would see this all the time, where you'd have just the most dire situation and the patient was 89 years old, has dementia, their quality of life wasn't there. But then the family is like, “Nope, we want them to do an ex-lap and we want them to do everything possible in order to save them.” I think it is a big issue right now, just within society in general, and we can use modalities like Grey's in order to kind of talk about those.
Dr. Farnan: I think hope is a powerful thing. I'm not an oncologist. Several of my colleagues who are have very strong feelings about the idea of the battle against cancer because it implies that if there's a fight that someone loses, and it's not. I think more importantly in terms of social media, it's less the idea perhaps of people with terminal illness. But I think the big concern really is around areas of chronic illness.
I think, specifically, thinking in the context of the opioid crisis, which is a big hot topic right now that's being discussed. The idea of stereotyping or classifying patients by a diagnosis, and providers and physicians and nonphysician providers alike having conversations about their impressions of individuals based on interactions, I think can be very destructive to the physician-patient relationship and can cause a lot of distrust.
I think that that can be incredibly problematic. You'll see people kind of vent about their interactions with patients who, for example, have chronic pain who are asking for pain medication. There’s a lot of suspicion, a lot of cynicism in the community. I think that that voice is one where we're missing the patient voice.
I think it's incredibly important to consider that we should be very much listening to and being proactive about looking for the patient voice, especially in social media and other venues. Because the individual experience of illness is something that's so important that we don't hear enough of.
There are individual patient groups where they find one another online and network about their specific diagnoses. I mean, there was a thread that I read last night about an individual who was a physician who was very active on Twitter, who has a diagnosis, who said, “I don't like emergency room docs to know that I have this disease because it's going to color all of their interactions with me.” I think, as a community, we can do better about not trying to put those biases into the community and the discussion.
But in terms of things like terminal illness and discussing how we approach that, again, I think it's important to include the patient voice in the conversation. And also trying to understand each patient's approach and what their understanding is. I mean, I will say that patients having access to and googling the Alex Trebek story, or Google just period, everybody has their MD. When you're on that second, third page of Google, you're pretty desperate.
But people have more access than they ever have had before. Between access and social media and the internet and direct-to-consumer marketing of different drugs, patients have a lot of information. And I think it makes a lot of people very uncomfortable that patients know so much about things these days. I think it's really important that we figure out how to include the patient voice and the patient experience before we throw out into the world what our views are of a disease.